Automatic injection device

ABSTRACT

An automatic injection device for providing a subcutaneous injection is disclosed. The device includes a syringe movably disposed in a housing and including a barrel portion, a needle and a bung for sealing the barrel portion. The device includes a plunger for moving the syringe towards a first open end of the housing such that the needle projects from the first end, and for subsequently applying pressure to the bung. The plunger includes a rod connected at a first end to the bung, a compressible expanded central portion, and a flange between a second end of the rod and the central portion. The device also includes a biasing mechanism for biasing the plunger towards the first open end of the housing, the biasing mechanism disposed about the second end of the rod between the flange and a second end of the housing.

CROSS REFERENCE TO RELATED APPLICATIONS

This is a continuation of U.S. application Ser. No. 13/267,467, filedOct. 6, 2011, which is a continuation of U.S. application Ser. No.12/074,704, filed Mar. 5, 2008, which is continuation of U.S.application Ser. No. 11/824,516, filed Jun. 29, 2007. U.S. applicationSer. No. 11/824,516 claims the benefit of priority to U.S. ProvisionalPatent Application Ser. No. 60/817,849, entitled AUTOMATIC INJECTIONDEVICE, filed Jun. 30, 2006; U.S. Provisional Patent Application Ser.No. 60/838,905, entitled AUTOMATIC INJECTION DEVICE, filed Aug. 18,2006; U.S. Provisional Patent Application Ser. No. 60/899,262, entitledMETHODS FOR MONITORING AND TREATING TNFα RELATED DISORDERS, filed Feb.2, 2007; U.S. Provisional Patent Application Ser. No. 60/849,967,entitled METHODS AND COMPOSITIONS FOR TREATING CROHN'S DISEASE, filedOct. 6, 2006; U.S. Provisional Patent Application Ser. No. 60/904,626,entitled METHODS AND COMPOSITIONS FOR TREATING CROHN'S DISEASE, filedMar. 1, 2007; U.S. Provisional Patent Application Ser. No. 60/918,174,entitled METHODS AND COMPOSITIONS FOR TREATING CROHN'S DISEASE, filedMar. 14, 2007; and U.S. Provisional Patent Application Ser. No.60/818,231, filed on Jun. 30, 2006. The contents of each of the abovepriority documents is incorporated by reference herein in entirety.

FIELD OF THE INVENTION

The present invention relates to an injection device for injecting asubstance, such as a drug, into a patient.

BACKGROUND OF THE INVENTION

One of the most common routes of administration for medications is byinjection, such as intravenous, subcutaneous or intramuscular injection.A syringe containing the medication is used for the injection, whichtypically is carried out by trained medical personnel. In certaininstances, a patient is trained in the use of the syringe to allow forself-injection. Moreover, certain medications are formulated inpre-filled syringes for patient use, to avoid the need for the patientto fill the syringe. Some patients, however, may be averse to carryingout self-injection, particularly if the patient has a fear of needles.

Automatic injection devices offer an alternative to a syringe fordelivering a medication. Automatic injection devices have been used, forexample, to deliver medications under emergency conditions, such as toadminister epinephrine to counteract the effects of a severe allergicreaction, for example, as caused by a food allergy. Automatic injectiondevices also have been described for use in administering antiarrhythmicmedications and selective thrombolytic agents during a heart attack (seee.g., U.S. Pat. Nos. 3,910,260; 4,004,577; 4,689,042; 4,755,169 and4,795,433). Various types of automatic injection devices also aredescribed in, for example, U.S. Pat. Nos. 3,941,130; 4,261,358;5,085,642; 5,092,843; 5,102,393; 5,267,963; 6,149,626; 6,270,479; and6,371,939.

In general, prior automatic injection devices, when operated, cause theneedle of a syringe to move forward and project from a protectivehousing prior to actuation of the syringe to eject a dose of liquidthrough the needle. Movement of the syringe toward the patient's skinsuch that the needle is exposed before pressurizing a liquid chargeinside the syringe helps prevent the liquid from dripping out of theneedle before the actual injection takes place.

Such prior automatic injection devices have several disadvantages. Forexample, prior devices include an exposed needle that a patient isrequired to inject into him or herself, causing apprehension and anxietyfor most patients, particularly those patients that are “needle phobic”.Prior devices are also difficult for patients to use, to maintain freeof contamination, and/or to provide an accurate dosage of medicine. Inaddition, patients suffering from chronic autoimmune diseases such asrheumatoid arthritis, as well as the elderly and physically disabled,may lack the dexterity needed to self-administer biologic therapiesusing existing injection devices. A need therefore exists for suchself-medication delivery devices that patients are able to use safelyand that foster patient adherence to their biologic therapy regimens.

TNFα inhibitors are effective in the treatment of autoimmune disorderssuch as rheumatoid arthritis, psoriatic arthritis and Crohn's Disease.Such inhibitors, which include biological agents such as antibodies andantibody fusion proteins, typically are delivered by injection. The TNFαinhibitor adalimumab (HUMIRA®; Abbott Laboratories, Lake County, Ill.),for example, has been marketed as a pre-filled syringe forself-administration by patients and therefore presents as an importantcandidate for use with an improved automatic injection devices andmethods.

SUMMARY OF THE INVENTION

The present invention provides improved devices, components thereof, andmethods of administering an injectable therapy to a patient. In anembodiment, the invention provides an automatic injection device forejecting a dose of fluid medication from a needle of a syringe movablydisposed within a housing of the device. Prior to use, the syringe ofthe invention is in a retracted position within the housing. During afirst operational stage, initiated by actuating an activation button, anactuator propels the syringe towards a proximal end of the housing toproject a needle of the syringe from the proximal end. In this firstoperational stage, the actuator causes the needle to be inserted into asubcutaneous region of the skin of the user when the proximal end of thedevice is held against an injection site. In a second operational stage,an actuator, which may be the same or a different component as theactuator that causes the needle to be inserted, causes the fluiddisposed within the syringe to be ejected into the subcutaneous region.

The automatic injection device of the invention may be used to inject adose of a tumor necrosis factor-α (TNFα) inhibitor to treat any numberof diseases, including rheumatoid arthritis, psoriasis, Crohn's disease,psoriatic arthritis, and juvenile rheumatoid arthritis. In oneembodiment, the user has a disorder in which TNFα is detrimentalselected from the group consisting of rheumatoid arthritis, psoriasis,Crohn's disease, ankylosing spondylitis, psoriatic arthritis, andjuvenile rheumatoid arthritis.

The automatic injection device may include a window to allow a user toview the contents and/or level of the contents of the syringe. Inaddition, the automatic injection device may include an indicator toindicate when an injection is complete. A “dummy” or demonstrationtraining automatic injection device may also be provided for training auser to use the automatic injection device to inject a substance withoutactually injecting a substance into the user.

The invention provides an automatic injection device for providing asubcutaneous injection of a substance into a user or patient, comprisinga housing having an open first end and a second end, a syringe movablydisposed in the housing, the syringe including a barrel portion forholding the substance, a hollow needle in fluid communication with thebarrel portion for ejecting the substance from the syringe, and a bungfor sealing the barrel portion and selectively applying pressure to thesubstance to force the substance through the hollow needle, a syringeactuation component for first moving the syringe towards the first endof the housing such that the needle projects from the first end and forsubsequently applying pressure to the bung, the syringe actuationcomponent including a pressurizer for selectively applying pressure tothe bung, a compressible expanded central portion and a flange between asecond end of the syringe actuation component and the compressibleexpanded central portion and a first biasing mechanism for biasing thesyringe actuation component towards the first open end of the housing,the first biasing mechanism disposed between the flange of the syringeactuation component and the second end of the housing.

In one embodiment, the automatic injection device further comprises anactivation button disposed on the housing for actuating the syringeactuation component. In another embodiment, the automatic injectiondevice includes an activation button coupled to the housing foractuating the syringe actuation component.

In another embodiment, the automatic injection device further comprisesa latch actuated by the activation button for latching the syringeactuation component in a retracted position prior to actuation by theactivation button.

The invention also includes an automatic injection device for providinga subcutaneous injection of a substance into a user, comprising ahousing having an open first end and a second end, a syringe movablydisposed in the housing, the syringe including a barrel portion forholding the substance, a hollow needle in fluid communication with thebarrel portion for ejecting the substance from the syringe, and a bungfor sealing the barrel portion and selectively applying pressure to thesubstance to force the substance through the hollow needle, an actuatorfor selectively moving the syringe towards a first end of the housing sothat the needle extends from the open first end of the housing and anactuator for expelling the substance from the syringe after movement ofthe syringe towards the open first end of the housing. A first removablecap may cover the first end of the housing.

The actuator may include a first biasing mechanism, a second biasingmechanism, a plunger-type syringe actuator and/or another actuatormeans.

In one embodiment, the automatic injection device further comprises adose of a substance, e.g., a TNF inhibitor, loaded in the barrel portionof the syringe.

Included in the invention, is an automatic injection device forproviding a subcutaneous injection of a substance into a user,comprising a housing having an open first end, a second end and a windowdisposed in a side wall for viewing the interior of the housing, asyringe movably disposed in the housing, the syringe including a barrelportion for holding the substance, a hollow needle in fluidcommunication with the barrel portion for ejecting the substance fromthe syringe, and a bung for sealing the barrel portion and selectivelyapplying pressure to the substance to force the substance through thehollow needle, an actuator for selectively moving the syringe towards afirst end of the housing so that the needle extends from the first endof the housing and an actuator for expelling the substance from thesyringe after movement of the syringe towards the first end of thehousing.

In one embodiment, the window has a substantially key-hole shape. In afurther embodiment, the window includes a fill line at a position in thewindow for indicating a full dose of the substance.

The invention further provides an automatic injection device forproviding a subcutaneous injection of a substance into a user,comprising a housing having an open first end and a second end, asyringe movably disposed in the housing, the syringe including a barrelportion for holding the substance, a hollow needle in fluidcommunication with the barrel portion for ejecting the substance fromthe syringe, and a bung for sealing the barrel portion and selectivelyapplying pressure to the substance to force the substance through thehollow needle, a syringe actuation component for selectively applyingpressure to the bung, the syringe actuation component including apressurizer configured to be inserted into the barrel portion of thesyringe, a compressible expanded central portion and an indicatordisposed between the compressible expanded central portion and a secondend of the syringe actuation component for indicating when the contentsof the syringe have been expelled.

The invention includes an automatic injection device for providing asubcutaneous injection of a substance into a user, comprising a housinghaving an open first end, a second end and having a window formed in aside wall thereof, a syringe movably disposed within the housing forstoring and selectively ejecting the substance from the open first end;and an indicator that aligns with the window in the side wall when thesyringe is substantially empty of the substance.

Another aspect of the invention includes an automatic injection device,comprising a housing having a substantially tubular configuration withan open first end and a second end; a syringe movably disposed withinthe housing, the syringe containing a dose of a substance, e.g., a TNFinhibitor, wherein the syringe moves within the housing to inject theTNF inhibitor into a user.

In one embodiment, the automatic injection device further comprises anindicator for indicating when the substance, e.g., a TNF inhibitor, hasbeen ejected from the syringe.

In one embodiment, the automatic injection device further comprises awindow formed in the housing to allow viewing of the interior of thehousing.

In one embodiment, the automatic injection device further comprises anindicator that aligns with the window when the substance, e.g., a TNFinhibitor, has been ejected from the syringe.

Another aspect of the invention is an automatic injection device forproviding a subcutaneous injection of a substance into a user,comprising a housing having an open first end and a second end; aplunger including a rod configured to be connected at a first end to abung of a syringe, a compressible expanded central portion and a flangebetween a second end of the rod and the compressible expanded centralportion; and a biasing mechanism for biasing the plunger towards thefirst open end of the housing, the biasing mechanism disposed about thesecond end of the rod between the flange and the second end of thehousing.

In one embodiment, the automatic injection device further comprises anactivation button disposed on the housing for actuating the plunger.

In one embodiment, the automatic injection device further comprises alatch actuated by the activation button for latching the plunger in aretracted position prior to actuation by the activation button.

In one embodiment of the invention, the automatic injection devicefurther comprises a window on the housing for viewing the interior ofthe housing.

In still another embodiment, the automatic injection device furthercomprises an indicator for indicating when the syringe is empty.

In another embodiment, the automatic injection device comprises asyringe comprising a dose of a substance, e.g., a TNF inhibitor, to beinjected into a user.

In still another embodiment, the automatic injection device furthercomprises a removable cap for covering one of the first end and thesecond end of the housing.

In one embodiment, the invention provides an automatic injection devicefurther comprising a needle sheath that advances over the needleprojecting through the first end after ejection of the substance fromthe syringe.

The invention features automatic injection device comprising a dose of aTNFα inhibitor, e.g., adalimumab. In one embodiment, the automaticinjection device further comprises a dose of a TNF inhibitor loaded inthe barrel portion of the syringe.

The invention includes a housing for an automatic injection device,comprising a hollow substantially tubular housing including an openfirst end and a second end, the hollow substantially tubular housingconfigured to slidably receive a syringe therein; a first stop in aninterior surface of the housing for limiting movement of the syringe ina first direction; and a second stop on the interior surface of thehousing for limiting movement of the syringe in a second direction.

In one embodiment, the housing further comprises a shelf formed betweenthe open first end and the first stop for seating a biasing mechanismfor biasing the syringe away from the first end of the housing. In oneembodiment, the housing further comprises a window formed in a side wallof the housing for allowing viewing of the interior of the housing. Inone embodiment, the housing further comprises an activation buttondisposed at the second end of the tubular housing for selectivelyactivating the syringe to move from a first, retracted position to asecond, projecting position where a needle of the syringe projects fromthe first end, and, while the syringe is in the second, projectingposition, apply pressure to eject a substance from the syringe.

The invention further includes a syringe for use in an automaticinjection device, comprising a barrel portion for containing asubstance; a hollow needle in fluid communication with the barrelportion; a bung for sealing the barrel portion, the bung movable withinthe barrel portion to increase pressure within the barrel portion toforce the substance through the hollow needle; a first stop formed on anintermediate portion of the barrel portion for abutting a stop in ahousing of the automatic injection device to limit movement of thesyringe in a first direction; and a second stop formed on a distal endof the barrel portion for limiting movement of the syringe relative tothe housing of the automatic injection device in a second direction. Inanother embodiment, the stops may be formed at other locationsthroughout the barrel.

In one embodiment, the syringe further comprises a plunger forselectively first moving the syringe towards an open first end of thehousing of the automatic injection device, such that the needle projectsfrom the first end, and subsequently applying pressure to the bung tocause the syringe to eject the substance through the hollow needle.

In one embodiment, the plunger comprises a rod connected at a first endto the bung and a compressible expanded central portion. In anotherembodiment, the plunger further includes an indicator for indicatingwhen the syringe has ejected substantially all of the substance throughthe hollow needle. In one embodiment, the syringe further comprises adose of a TNF inhibitor loaded in the barrel portion of the syringe.

The invention further provides a syringe actuation component for aninjection device, comprising a rod portion having a first end, a secondend and a compressible expanded central portion, and a pressurizerformed on the first end of the rod portion for applying pressure to abung of a syringe.

In one embodiment, the syringe actuation component further comprises ananchoring portion formed on a second end of the rod portion foranchoring a coil spring to the syringe actuation component. In oneembodiment, the syringe actuation component further comprises anindicator for indicating completion of an injection formed in a solidrod portion between the compressible expanded central portion and thesecond end of the rod portion. In one embodiment, the syringe actuationcomponent further comprises a retaining flange for holding the coilspring in a compressed position until actuation. In one embodiment, thesyringe actuation component further comprises a spring base for the coilspring extending between the anchoring end and the retaining flange. Inone embodiment, the spring base comprises flexible legs around thespring coils. In another embodiment, the anchoring end comprises tabbedfeet extending from the base and configured to releasably engage anactivation button.

The invention further provides an article of manufacture comprising apackaging material and an automatic injection device comprising a TNFαinhibitor. In one embodiment, the TNFα inhibitor comprises adalimumab.In one embodiment, the dose of adalimumab is 40 mg. The article ofmanufacture may also comprise an alcohol prep and/or a dose tray forholding the automatic injection device.

The invention also provides an article of manufacture comprising anautomatic injection device having a pre-filled syringe containing a doseof a TNFα inhibitor; and an alcohol preparation pad, packaged withinstructions for use to treat arthritis by injecting the dose into theskin of a user using the automatic injection device.

The invention also provides an article of manufacture comprising: anautomatic injection device having a pre-filled syringe containing a doseof a TNFα inhibitor; and an alcohol preparation pad, packaged withinstructions for use to treat arthritis by injecting the dose into theskin of a user using the automatic injection device.

The invention also includes a method of injecting a substance,comprising the steps of providing an automatic injection devicecomprising a housing having an open first end, a second end, a syringemovably disposed within the housing containing the substance, a capcovering the first end and a cap covering an activating button on thesecond end; removing the first cap; removing a second cap to expose theactivating button; positioning the open first end of the device adjacentthe skin of a user; actuating the activating button to cause a needle ofthe syringe to first project from the open first end and into the skinof the user and subsequently ejecting the substance through the needlean into a subcutaneous region of the user; and removing the device afterthe substance is ejected.

In one embodiment, the automatic injection device is held at about a 90degree angle relative to the skin of the user. In one embodiment, anindicator provides an indication to the user when the syringe issubstantially empty of the substance. In one embodiment, the substanceloaded and ejected from the syringe is a dose of a TNF inhibitor.

In still another embodiment of the invention, the method includes (a)positioning the automatic injection device at an injection site of theuser; (b) engaging the activator mechanism to begin injection of thesubstance to the user; (c) maintaining engagement of the activatormechanism for a prescribed period of time to continue injection of thesubstance; and (d) removing the automatic injection device from theinjection site after passage of the prescribed period of time.

In yet another embodiment of the invention, the method includes (a)positioning the automatic injection device at an injection site; (b)engaging the activator mechanism to begin injection of the substance tothe user; (c) maintaining engagement of the activator mechanism tocontinue injection of the substance until a visible indicator ofcompletion is detected; and (d) removing the automatic injection devicefrom the injection site once the visible indicator of completion isdetected.

The invention also features a method of training a recipient on use ofan automatic injection device.

One aspect of the invention is a device for training a recipient to usean automatic injection device, comprising a housing having a window, anactivation button on a first end of the housing; and an indicatormovably disposed within the housing, wherein the indicator aligns withthe window of the housing after a user activates the activation button.

In an embodiment, the device further comprises an activation componentfor selectively moving the indicator from a hidden position to aposition aligned with the window. In one embodiment, the activationcomponent comprises a rod having an anchoring portion on a first endthat is selectively latched by the activation button, a flanged portionfor retaining a biasing mechanism towards the first end of the housing,and wherein the indicator is formed between a second end of the rod andthe flanged portion.

The invention also provides a kit for training a recipient on use of anautomatic injection device, wherein the automatic injection devicecomprises a needle and a medication, the kit comprising: (a) ademonstration automatic injection device which lacks the needle and themedication; and (b) instructions for using the automatic injectiondevice.

In one embodiment, the instructions convey a method to the recipient forusing the demonstration automatic injection device, the methodcomprising: (a) position the automatic injection device at an injectionsite; (b) engage the activator mechanism to begin injection of themedication; (c) maintain engagement of the activator mechanism for aprescribed period of time to continue injection of the medication; and(d) remove the automatic injection device from the injection site afterpassage of the prescribed period of time.

In one embodiment, the prescribed period of time is 10 seconds. Inanother embodiment, the prescribed period of time is at least 10seconds.

In one embodiment, the instructions further convey that initialengagement of the activator mechanism is accompanied by an audiblesound. In another embodiment, the instructions further convey thatcompletion of injection of the medication is accompanied by a visibleindicator of completion.

In one embodiment, the instructions further convey that the injectionsite may be sterilized prior to positioning the automatic injectiondevice at the injection site.

In one embodiment, the instructions further convey that the automaticinjection device be examined for proper dosage and formulation of themedication prior to positioning the automatic injection device at theinjection site.

In one embodiment, the instructions further convey to the recipient, atleast one message selected from the group consisting of: (a) theautomatic injection device is less painful for a patient to use than apre-filled syringe; (b) the automatic injection device is preferred foruse by patients as compared to a pre-filled syringe; (c) the automaticinjection device is easier to use by a patient than a pre-filledsyringe; (d) the automatic injection device is more convenient for apatient to use than a pre-filled syringe; (e) the automatic injectiondevice reduces anxiety of patients with a fear of needles, as comparedto a pre-filled syringe, since the needle is not visible in the device;and (f) the automatic injection device is designed to be easy to usefrom initial use of the device.

In one embodiment, the recipient is a physician that prescribes themedication. In another embodiment, the recipient is a patient that usesthe medication. In yet another embodiment, the recipient is acare-giver, such as a family member.

The invention also includes a demonstration automatic injection devicecomprising a housing having an open first end, a second end, and havinga window formed in a side wall thereof,a syringe movably disposed withinthe housing; an activator mechanism associated with the syringe fordepressing the syringe; and an indicator that aligns with the window inthe side wall when the syringe is fully depressed.

The invention features an audiovisual device for promoting an automaticinjection device comprising a medication to a recipient, wherein thedevice conveys to the recipient at least one message selected from thegroup consisting of: (a) the automatic injection device is less painfulfor a patient to use than a pre-filled syringe; (b) the automaticinjection device is preferred for use by patients as compared to apre-filled syringe; (c) the automatic injection device is easier to useby a patient than a pre-filled syringe; (d) the automatic injectiondevice is more convenient for a patient to use than a pre-filledsyringe; (e) the automatic injection device reduces anxiety of patientswith a fear of needles, as compared to a pre-filled syringe, since theneedle is not visible in the device; and (f) the automatic injectiondevice is designed to be easy to use from initial use of the device.

The invention also includes an audiovisual device or printed materialfor training a recipient on the use of an automatic injection device,wherein the automatic injection device comprises an activator mechanismand a medication, the audiovisual device conveying to the recipientinstructions to: (a) position the automatic injection device at aninjection site; (b) engage the activator mechanism to begin injection ofthe medication; (c) maintain engagement of the activator mechanism for aprescribed period of time to continue injection of the medication; and(d) remove the automatic injection device from the injection site afterpassage of the prescribed period of time.

The invention also includes an audiovisual device or printed materialfor for training a recipient on the use of an automatic injectiondevice, wherein the automatic injection device comprises an activatormechanism and a medication, the audiovisual device conveying to therecipient instructions to: (a) position the automatic injection deviceat an injection site; (b) engage the activator mechanism to begininjection of the medication; (c) maintain engagement of the activatormechanism to continue injection of the medication until a visibleindicator of completion is detected; and (d) remove the automaticinjection device from the injection site once the visible indicator ofcompletion is detected.

The invention further provides a method of training a recipient on theuse of an automatic injection device, wherein the automatic injectiondevice comprises an activator mechanism and a medication. The methodcomprises, in one embodiment, conveying to the recipient instructionsto: (a) position the automatic injection device at an injection site;(b) engage the activator mechanism to begin injection of the medication;(c) maintain engagement of the activator mechanism to continue injectionof the medication until a visible indicator of completion is detected;and (d) remove the automatic injection device from the injection siteonce the visible indicator of completion is detected.

In one embodiment, the automatic injection device comprises an indicatorwindow and the visible indicator of completion comprises a colorindicator, e.g., yellow, appearing in the indicator window.

In one embodiment, the instructions further convey that initialengagement of the activator mechanism is accompanied by an audiblesound.

In one embodiment, the instructions further convey that engagement ofthe activator mechanism is maintained for a prescribed period of time,e.g., 10 seconds, to continue injection of the medication. In oneembodiment, the instructions further convey that the injection site besterilized prior to positioning the automatic injection device at theinjection site.

In one embodiment, the instructions further convey that the automaticinjection device be examined for proper dosage and formulation of themedication prior to positioning the automatic injection device at theinjection site.

In another aspect, the invention pertains to a method of training a useron the use of an automatic injection device, wherein the automaticinjection device comprises a needle and a medication, the methodcomprising providing to the user: (a) a demonstration automaticinjection device which lacks the needle and the medication; and (b)instructions for using the automatic injection device.

In yet another aspect, the invention pertains to a kit for training arecipient on the use of an automatic injection device comprises a needleand a medication, the kit comprising: (a) a demonstration or “trainer”automatic injection device which lacks the needle and the medication;and (b) instructions for using the automatic injection device.

In yet another aspect, the invention pertains to a method of training arecipient on the use of an automatic injection device, wherein theautomatic injection device comprises an activator mechanism and amedication. The training method comprises conveying to the recipientinstructions to: (a) position the automatic injection device at aninjection site; (b) engage the activator mechanism to begin injection ofthe medication; (c) maintain engagement of the activator mechanism for aprescribed period of time to continue injection of the medication; and(d) remove the automatic injection device from the injection site afterpassage of the prescribed period of time.

Preferred prescribed periods of time for engaging the activatormechanism include 10 seconds, or engaging the activator mechanism for atleast 10 seconds. In certain embodiments, the instructions furtherconvey that initial engagement of the activator mechanism is accompaniedby an audible sound. In certain embodiments, the instructions furtherconvey that completion of injection of the medication is accompanied bya visible indicator of completion. In certain other embodiments, theinstructions further convey that the injection site be sterilized priorto positioning the automatic injection device at the injection site. Incertain embodiments, the instructions further convey that the automaticinjection device should be examined for proper dosage and formulation ofthe medication prior to positioning the automatic injection device atthe injection site.

In another aspect, the invention pertains to a method of training arecipient on the use of an automatic injection device, wherein theautomatic injection device comprises an activator mechanism and amedication. The training method comprises conveying to the recipientinstructions to: (a) position the automatic injection device at aninjection site; (b) engage the activator mechanism to begin injection ofthe medication; (c) maintain engagement of the activator mechanism tocontinue injection of the medication until a visible indicator ofcompletion is detected; and (d) remove the automatic injection devicefrom the injection site once the visible indicator of completion isdetected.

In a preferred embodiment, the automatic injection device comprises anindicator window and the visible indicator of completion comprises acolor indicator appearing in the indicator window. The color indicatorcan be, for example, a yellow color indicator.

In one embodiment, the instructions are provided in a printed documentor in an audiovisual device. In another embodiment, the audiovisualdevice is a Video Home System (VHS) cassette or a Digital Video Disc(DVD). In one embodiment, the instructions are conveyed orally to therecipient.

In one embodiment, the recipient is a physician that prescribes themedication. In one embodiment, the recipient is a patient that uses themedication.

The invention also includes an article of manufacture comprising apackaging material; a TNFα inhibitor, such as adalimumab; and a label orpackage insert contained within the packaging material indicating thatin studies of the TNFα inhibitor using the automatic injection device ofthe invention for the treatment of a disorder in which TNFα isdetrimental, such as rheumatoid arthritis, the most common adverseevents (AEs) were bronchitis, hypersensitivity, arthritic pain, coughand rhinitis.

The invention further provides an article of manufacture comprising: apackaging material; an automatic injection device, e.g., an autoinjectorpen filled with a TNFα inhibitor; and a label or package insertcontained within the packaging material indicating that thebioequivalence of the TNFα inhibitor is similar regardless of whetherthe injection site is the thigh or abdomen.

The article of manufacture of the invention may comprise a label. In oneembodiment, the label of the invention indicates how the TNFα inhibitor,e.g., TNF antibody, or antigen binding portion thereof, is packaged asan article of manufacture. In one embodiment, the label of the inventionindicates the TNFα inhibitor, e.g., TNF antibody, or antigen bindingportion thereof, is dispensed in a carton containing 6 alcohol preps and6 dose trays (e.g., labeled Crohn's Disease Starter Package). In anotherembodiment, the label indicates that each dose tray consists of asingle-use pen each pen, containing a 1 mL prefilled glass syringe witha fixed 27 gauge ½ inch needle, providing 40 mg (0.8 mL) of the TNFαinhibitor.

The present invention relates to automatic injection devices foradministering medications and in particular relates to compositions andmethods for promoting the use of such devices and to compositions andmethods for training users (e.g., patients and medical personel) in theuse of such devices. The invention is based, at least in part, onresults of a clinical study comparing an automatic injection device foradministering adalimumab (HUMIRA®) to a pre-filled syringe foradministering adalimumab (HUMIRA®). The study revealed numerousadvantageous features of the automatic injection device and identifiedparticular aspects of using the device to be highlighted when trainingsomeone to use the device.

Accordingly, in one aspect, the invention pertains to a method ofpromoting an automatic injection device comprising a medication to arecipient. The method comprises conveying to the recipient at least onemessage selected from the group consisting of: (a) the automaticinjection device is less painful for a patient to use than a pre-filledsyringe; (b) the automatic injection device is preferred for use bypatients as compared to a pre-filled syringe; (c) the automaticinjection device is easier to use by a patient than a pre-filledsyringe; (d) the automatic injection device is more convenient for apatient to use than a pre-filled syringe; (e) the automatic injectiondevice reduces anxiety of patients with a fear of needles, as comparedto a pre-filled syringe, since the needle is not visible to the userwhile using the device; and (f) the automatic injection device isdesigned to be easy to use from the initial use of the device.

In a preferred embodiment, the message conveyed to the user is that theautomatic injection device is less painful for a patient to use than apre-filled syringe, for example that 80% of patients in a clinical trialrated the automatic injection device as less painful than a pre-filledsyringe. In another preferred embodiment, the message conveyed to therecipient is that the automatic injection device is preferred for use bypatients as compared to a pre-filled syringe, for example that 90% ofpatients in a clinical trial preferred the automatic injection device toa pre-filled syringe.

In certain embodiments, the user is conveyed the information that theautomatic injection device comprises a five bevel needle, as compared toa three bevel needle for a pre-filled syringe.

In another aspect, the invention pertains to an audiovisual device forpromoting an automatic injection device comprising a medication to auser, wherein the device conveys to the user at least one of themessages provided above. In the methods and compositions of theinvention, the promotional messages or training instructions can beconveyed, for example, orally to the recipient and/or in writing to therecipient. Alternatively or in addition, the audiovisual device can be,for example, a Video Home System (VHS) cassette or a Digital Video Disc(DVD).

In the methods of the invention, the recipient of the promotionalmessages or training instructions can be, for example, a physician thatprescribes the medication, a patient that uses the medication, or acaregiver.

In the methods and compositions of the invention, preferably theautomatic injection device provides for subcutaneous injection of themedication. Preferred embodiments of the automatic injection device aredescribed herein.

The automatic injection device used in the methods and compositions ofthe invention may comprise a substance or medication that is, forexample, an antibody, a cytokine, a vaccine, a fusion protein or agrowth factor. In a preferred embodiment, the medication is a TNFαinhibitor (e.g., an anti-TNF antibody or an antigen-binding portionthereof, a TNF fusion protein, or a recombinant TNF binding protein),such as infliximab (Remicade™, Centocor, Horsham, Pa.), CDP 571, CDP870, anti-TNF dAb, golimumab, adalimumab, etanercept (Enbrel™, Amgen,Calif.), p55TNFR1gG (Lenercept) or r-TBP-1. A particularly preferredmedication for use in the automatic injection device is adalimumab(HUMIRA®). Another particularly preferred medication for use in theautomatic injection device is an isolated human antibody thatdissociates from human TNFα with a K_(d) of 1×10⁻⁸ M or less and aK_(off) rate constant of 1×10⁻³ s⁻¹ or less, both determined by surfaceplasmon resonance, and neutralizes human TNFα cytotoxicity in a standardin vitro L929 assay with an IC₅₀ of 1×10⁻⁷ M or less. In one embodiment,the automatic injection device, including uses and compositions thereof,comprises a dose of a TNFα inhibitor.

In one embodiment, the anti-TNFα antibody, or antigen-binding portionthereof, is selected from the group consisting of a chimeric antibody, ahumanized antibody, a human antibody, and a multivalent antibody.

In one embodiment, the anti-TNFα antibody is an isolated human antibody,or antigen-binding portion thereof, with the following characteristics:a) dissociates from human TNFα with a K_(off) rate constant of 1×10⁻³s⁻¹ or less, as determined by surface plasmon resonance; b) has a lightchain CDR3 domain comprising the amino acid sequence of SEQ ID NO: 3, ormodified from SEQ ID NO: 3 by a single alanine substitution at position1, 4, 5, 7 or 8 or by one to five conservative amino acid substitutionsat positions 1, 3, 4, 6, 7, 8 and/or 9; and c) has a heavy chain CDR3domain comprising the amino acid sequence of SEQ ID NO: 4, or modifiedfrom SEQ ID NO: 4 by a single alanine substitution at position 2, 3, 4,5, 6, 8, 9, 10 or 11 or by one to five conservative amino acidsubstitutions at positions 2, 3, 4, 5, 6, 8, 9, 10, 11 and/or 12.

In one embodiment, the anti-TNFα antibody is an isolated human antibody,or an antigen binding portion thereof, with a light chain variableregion (LCVR) comprising the amino acid sequence of SEQ ID NO: 1 and aheavy chain variable region (HCVR) comprising the amino acid sequence ofSEQ ID NO: 2

In one embodiment, the anti-TNFα antibody, or antigen-binding portionthereof, is selected from the group consisting of infliximab, golimumab,and adalimumab

In one embodiment, the TNFα inhibitor is selected from the groupconsisting of infliximab, CDP 571, CDP 870, anti-TNF dAb, golimumab,adalimumab, etanercept, p55TNFRIgG and r-TBP-1.

In one embodiment, the substance that is loaded into the automaticinjection device is a formulation comprising adalimumab, sodiumchloride, monobasic sodium phosphate dihydrate, dibasic sodium phosphatedihydrate, sodium citrate, citric acid monohydrate, mannitol,polysorbate 80, and water.

In one embodiment, the automatic injection device is used to deliver ananti-TNFα antibody, or antigen-binding portion thereof, to a used,wherein administration is given on a biweekly dosing regimen or amultiple variable dose regimen.

BRIEF DESCRIPTION OF THE FIGURES

The foregoing and other objects, features and advantages of the presentinvention, as well as the invention itself, will be more fullyunderstood from the following description of preferred embodiments whenread together with the accompanying drawings, in which:

FIG. 1 is a perspective view of the automatic injection device accordingto an illustrative embodiment of the invention.

FIG. 2 is an exploded view of the automatic injection device accordingto an illustrative embodiment of the invention.

FIG. 3 is a cross-sectional schematic view of an automatic injectiondevice of an embodiment of the invention prior to use.

FIG. 4 is a cross-sectional schematic view of the automatic injectiondevice of FIG. 3 during a subsequent stage of operation.

FIG. 5 is a cross-sectional schematic view of the automatic injectiondevice of FIG. 3 during a final stage of operation.

FIG. 6 illustrates an embodiment of an automatic injection deviceaccording to one embodiment of the invention.

FIG. 7 is an exploded view of the firing mechanism assembly of theautomatic injection device of FIG. 6 according to an illustrativeembodiment of the invention.

FIGS. 8A-8C are different views illustrating the distal housingcomponent, coil spring and syringe actuation component of the firingmechanism assembly of FIG. 7 when assembled without the activationbutton.

FIG. 9 is a perspective view of the distal housing component of thefiring mechanism assembly of FIG. 7.

FIG. 10 is a perspective view of the syringe actuation component of thefiring mechanism assembly of FIG. 7.

FIG. 11 is an exploded view of the syringe housing assembly of theautomatic injection device of FIG. 6 according to an illustrativeembodiment of the invention.

FIG. 12 illustrates an embodiment of the syringe carrier of the syringehousing assembly of FIG. 11.

FIG. 13 illustrates an embodiment of the stepped shroud of the syringehousing assembly of FIG. 11.

FIG. 14 illustrates an embodiment of the proximate cap of the syringehousing assembly of FIG. 11.

FIGS. 15 a and 15 b are a perspective side view and a cross-sectionalside view, respectively, of the assembled spring housing assembly ofFIG. 11 according to one embodiment of the invention.

FIGS. 16A and 16B are cross-sectional views at 90 degree offset anglesfrom each other, illustrate an assembled automatic injection device,wherein a syringe housing assembly and a firing mechanism assembly arecoupled together.

FIG. 17 is a detailed view of the interface between a syringe housingassembly and a firing mechanism assembly of an automatic injectiondevice of an embodiment of the invention, illustrating the indicator ofthe syringe actuation component according to one embodiment of theinvention.

FIGS. 18-22 are cross-sectional view of an automatic injection deviceaccording to another embodiment of the invention.

FIG. 23 is a detailed view of the display window of an automaticinjection device according to one embodiment of the invention.

FIG. 24 illustrates use of an automatic injection device of anillustrative embodiment of the invention to inject a drug, such as a TNFinhibitor, into a subcutaneous region of a user.

FIG. 25 illustrates a diagram of the autoinjection pen forself-administration of adalimumab.

FIG. 26 shows results of final patient preference survey following Visit3.

FIG. 27 shows results showing the likelihood of switching to pen andlikelihood of recommending the pen to others.

DETAILED DESCRIPTION OF THE INVENTION

The present invention provides automatic injection devices, componentsthereof, and methods for injecting a substance, such as a liquid drug,into a patient to manage or cure a medical condition. In one embodiment,the automatic injection device is a pen, i.e., an autoinjector pen orautoinjection pen (used interchangeably herein). The present inventionalso provides a demonstration or “trainer” automatic injection device,which may be used to train a patient how to use an automatic injectiondevice.

The present invention also relates to automatic injection devices foradministering substances (also referred to herein as medications) and inparticular relates to compositions and methods for promoting the use ofsuch devices and to compositions and methods for training people in theuse of such devices. The invention is based, at least in part, onresults of a clinical study comparing an automatic injection device foradministering adalimumab (HUMIRA®) to a pre-filled syringe foradministering adalimumab (HUMIRA®). The study, described in detail inExamples 1 and 2 herein, revealed numerous advantageous features of theautomatic injection device of the invention and identified particularaspects of methods of using the device that should be highlighted whentraining a recipient to use the device.

I. Definitions

So that the invention may be more readily understood, certain terms aredefined, as follows:

As used herein, an “automatic injection device” (or “autoinjector”) isintended to refer to a device that enables an individual (also referredto herein as a user or a patient) to self-administer a dosage of asubstance, such as a liquid medication, wherein the device differs froma standard syringe by the inclusion of a mechanism for automaticallydelivering the medication to the individual by injection when themechanism is engaged.

As used herein, the term “pre-filled syringe” is intended to encompass asyringe that is filled with a medication immediately prior toadministration of the medication to an individual and a syringe that isfilled with a medication and stored in this pre-filled form for a periodof time before administration of the medication to an individual.

As used herein, a “recipient” is intended to refer to any person orindividual that receives the promotional messages or traininginstructions of the methods and compositions of the invention describedherein. Preferred recipients include physicians that prescribe themedication to be administered by the automatic injection device, andpatients that use the medication to be administered by the automaticinjection device, and their caregivers.

As used herein, the term “conveying to the recipient” is intended toencompass any means by which a promotional message or traininginstruction of the methods and compositions of the invention describedherein is communicated to or expressed to a recipient. Non-limitingexamples of means for conveying a message or instruction to a recipientinclude oral communication, written communication and communication viaan audiovisual device.

As used herein, the term “initial use of the device” is intended torefer to the first time the automatic injection device is used toadminister a substance, e.g., a medication, to an individual.

As used herein, the term “printed document” is intended to refer to anydocument that has written communication printed on it. Non-limitingexamples of printed documents include brochures, leaflets, productinserts, flyers, flipcharts, tent cards and package labels.

As used herein, the term “audiovisual device” is intended to refer toany device that is capable of communicating information in auditory andvisual form. Non-limiting examples of audiovisual devices include VideoHome System (VHS) cassettes, Digital Video Discs (DVDs), CD-ROMS,digital videocassettes, 8 mm or 35 mm films and computers displayingWebcasts.

As used herein, the term “demonstration automatic injection device” or“a device for training” or “trainer” is intended to refer to anautomatic injection device that is used to demonstrate the procedure forusing the automatic injection device, including the look and feel ofusing the device, but which is not suitable for administering asubstance, e.g., a medication, because it lacks one or more necessarycomponents for administration of a substance, e.g., a medication and/ora needle. In a preferred embodiment, the demonstration automaticinjection device lacks a needle and the substance, e.g., a medication,as compared to the automatic injection device.

II. Automatic Injection Device of Invention

The invention will be described below relative to certain illustrativeembodiments. While the present invention is described with respect tousing the device to provide a subcutaneous injection of a dose of a TNFinhibitor, one skilled in the art will recognize that the invention isnot limited to the illustrative embodiment, and that the injectiondevice may be used to inject any suitable substance into a user. Inaddition, the components and the method of using the automatic injectiondevice are not limited to the illustrative embodiments described below.

As used herein, the term “distal” refers to the portion or end of anautomatic injection device or component in the automatic injectiondevice furthest from an injection site of the user when the device isheld against the person for an injection or for mimicking an injection.The term “proximal” refers to the portion or end of an automaticinjection device or a component of the automatic injection deviceclosest to an injection site of the user during an injection.

FIGS. 1 and 2 superficially illustrate an automatic injection device 10suitable for subcutaneously injecting a dose of a substance, such as aliquid drug, into a patient according to an illustrative embodiment ofthe invention. The automatic injection device 10 includes a housing 12for housing a container, such as a syringe, containing a dose of asubstance to be injected into a patient, as described in detail below.The housing 12 preferably has a tubular configuration, though oneskilled in the art will recognize that the housing 12 may have anysuitable size, shape and configuration for housing a syringe or othercontainer of a substance to be injected. While the invention will bedescribed with respect to a syringe mounted in the housing 12, oneskilled in the art will recognize that the automatic injection device 10may employ any suitable container for storing and dispensing asubstance.

Referring to FIG. 2, the syringe is preferably slidably mounted in thehousing 12, as described in detail below. In an inactivated position,the syringe is sheathed and retracted within the housing 12. When thedevice is actuated, a needle of the syringe projects from a first(proximal) end 20 of the housing 12 to allow ejection of a substancefrom the syringe into a patient. As shown, the first end of the housing20, i.e., the proximal end, includes an opening 28 through which theneedle of the syringe projects during actuation of the device 10.

Continuing to refer to FIGS. 1 and 2, a second (distal) end 30 of thehousing 12, i.e., the distal end, includes an activation button 32 foractuating the syringe to move from a sheathed position within thehousing 12 to a projecting position, and subsequently to expel thesubstance from the needle into the patient. The housing 12 houses one ormore actuators that perform the functions of moving the syringe andexpelling the substance from the syringe.

The illustrative automatic injection device 10 shown in FIGS. 1 and 2may also include a first removable cap 24 (or needle cap) for coveringthe first end 20 of the housing 12, to prevent exposure of the needle inthe syringe prior to use. In the illustrative embodiment, the first cap24 may include a boss 26 for locking and/or covering the interiorcomponents of the device 10 until the user is ready to activate thedevice 10. Alternatively, the first cap 24 may comprise a threaded screwportion and the internal surface of the housing 12 at opening 28 maycomprise screw thread. Any suitable mating mechanism may be used inaccordance with the teachings of the invention.

A second removable cap 34 (or actuator cap) may cover the second end 30of the housing 12 to prevent accidental actuation of the activationbutton 32.

The second cap 34 may have a distinctive color to differentiate thefirst end 20 and second end 30 of the device, though one skilled in theart will recognize that the cap 34 and housing 12 may have any suitablecolor, size and configuration.

In the illustrative embodiment of FIGS. 1 and 2, the housing 12 and caps24 and 34 may further include graphics, symbols and/or numbers tofacilitate use of the automatic injection device 10. For example, in theillustrative embodiment, the housing 12 includes an arrow 125 on anouter surface pointing towards the first end 20 of the device toindicate how the device 10 should be held relative to the patient (i.e.,with the first end 20 adjacent to the injection site), as shown in FIG.2. In addition, the first cap 24 is labeled with a “1” to indicate thata user should remove the first cap 24 of the device first, and thesecond cap is labeled with a “2” to indicate that the second cap 34should be removed after the first cap 24 is removed during preparationfor and subsequent injection using the illustrative automatic injectiondevice 10. One skilled in the art will recognize that the automaticinjection device 10 may have any suitable graphics, symbols and/ornumbers to facilitate user instruction, or the automatic injectiondevice may omit such graphics, symbols and/or numbers.

As shown in FIG. 2, the first end 20 of the housing 12 may have a widerdiameter than the second end 30. A step 29 may be formed at thetransition between the two diameters to accommodate the second cap 34 tofacilitate seating of the second cap 34 on the second end 30 of thehousing.

As illustrated in FIGS. 1 and 2, the housing 12 also preferably includesa display window 130 to allow a user to view the contents of the syringehoused within the housing 12, as described in detail below. The window130 may comprise an opening in the sidewall of the housing 12, or maycomprise a translucent material in the housing 12 to allow viewing ofthe interior of the device 10.

The housing 12 may be formed of any suitable surgical material,including, but not limited to, plastic and other known materials.

FIGS. 3-5 are schematic views of interior components of an automaticinjection device 10 according to one embodiment of the invention. Asshown, a syringe 50 or other suitable container for a substance isdisposed within the interior of the housing 12. The illustrative syringe50 includes a hollow barrel portion 53 for holding a dose of a liquidsubstance to be injected. The illustrative barrel portion 53 issubstantially cylindrical in shape, though one skilled in the art willrecognize that the barrel portion 53 may have any suitable shape orconfiguration. A seal, illustrated as a bung 54, seals the dose withinthe barrel portion 53. The syringe 50 may further include a hollowneedle 55 connected to and in fluid communication with the barrelportion 53, through which the dose can be ejected by applying pressureto the bung 54. The hollow needle 55 extends from a first, proximal end53 a of the barrel portion 53. The second end 53 b of the barrel portion53 includes a flange 56, or other suitable mechanism, for abutting astop, represented schematically as 123, in the housing 12 to limit themovement of the syringe 50 within the housing 12, as described below.One skilled in the art will recognize that the invention is not limitedto the illustrative embodiment of the syringe 50 and that any suitablecontainer for containing a dose of a substance to be injected may beused in accordance with the teachings of the invention. In theillustrative embodiment of FIGS. 3-5, the needle 55 is a fixedtwenty-seven gauge one-half inch needle. The tip of the illustrativehollow needle 55 may include five bevels to facilitate insertion.However, the needle 55 may have any suitable size, shape andconfiguration suitable for piercing a user's skin to deliver a substanceto a subcutaneous region and is not limited to the illustrativeembodiment. Suitable types of needles are well-known in the art.

The automatic injection device 10 shown in FIGS. 3-5 further includes asyringe actuator 70, illustrated as a plunger, for selectively movingand actuating the syringe 50 to inject the dose contained in the syringe50 into a user. The illustrative plunger 70 includes a rod portion 71having a first end 71 a integral with, connected to or in fluidcommunication with the bung 54 for selectively applying pressure to thebung 54 to expel the dose from the needle 55. The plunger 70 may includea flanged second end 72.

In an embodiment, the syringe activator comprises multiple componentsand/or more actuators are present in the automatic injection device ofthe invention.

The plunger 70 of FIGS. 3-5 is biased forward towards the first end 20of the device 10 by a first biasing mechanism, illustrated as a coilspring 88 disposed about or above a flanged second end of the plunger70. In the embodiment illustrated in FIGS. 3-5, a proximate end 88 a ofthe coiled spring 88 abuts the flanged second end 72 of the plunger 70to selectively apply pressure and move the plunger 70 proximally.Alternatively, the plunger 70 extends through the center of the spring88. Prior to use of the device 10, the coil spring 88 (or anothersuitable mechanism) is compressed between the plunger 70 and the housing12, storing energy. A trigger 91, which is activated by any suitableactuation means, such as the activation button 32 shown in FIGS. 1 and2, retains the plunger 70 and first biasing mechanism 88 in a retracted,latched position, shown in FIG. 3, the activation button 32 isactivated. In the illustrative embodiment, the trigger 91 latches theflanged second end 72 of the plunger 70. When a user activates theactivation button 32 or other actuation means, the trigger 91 releasesthe flanged second end 72 of the plunger 70, allowing the coil spring88, which applies pressure to the flanged second end 72, to propel theplunger 70 towards the first end of the device 10.

A second biasing mechanism, illustrated as a coil spring 89 in FIGS.3-5, holds the syringe 50 in a retracted position within the housing 12prior to use, as shown in FIGS. 1 and 3. In the retracted position, theneedle 55 is preferably sheathed entirely within the housing 12. Theillustrative syringe coil spring 89 is disposed about the proximalportion of the barrel portion 53 and may be seated in a shelf 121 formedwithin the housing interior. The top end of the coil spring 89 abuts theflanged second end 56 of the syringe 50. The spring force of the secondbiasing mechanism 89 pushes the flanged second end 56 of the syringe 50away from the first end 20 of the housing 12, thereby holding thesyringe 50 in the retracted position until activated. Other componentsof the device 10 may also position the syringe 50 relative to thehousing 12.

The first biasing mechanism 88 and the second biasing mechanism 89 mayhave any suitable configuration and tension suitable for use in biasingcertain components of the device. For example, the first biasingmechanism 88 has any suitable size, shape, energy and propertiessuitable for moving the plunger 70 and syringe 50 forward when released.The second biasing mechanism 89 has any suitable size, shape, energy andproperties suitable for retracting the syringe 50 prior to activation.Other suitable means for facilitating movement and expulsion from thesyringe may also be used.

Referring still to the illustrative embodiment of FIGS. 3-5, the plunger70 further includes a compressible expanded central portion 76. In theillustrative embodiment, the rod 71 is split in the central portion toform a pair of projecting elbows 78 that define the compressibleexpanded central portion 76. The projecting elbows 78 may be pre-formedas part of the molded plunger 70, or may be attached to the plunger 70separately. The projecting elbows 78 are compressible, so that they canbe moved radially inwardly to cause that portion of the rod to adopt acircumference similar to the rest of the rod. The compressible expandedcentral portion 76 facilitates movement, of the syringe 50, followed byexpulsion of the dose in two substantially separate stages, as describedbelow.

As shown in FIG. 4, when an activation means 320 activates the trigger91 to release the plunger 70, the spring force of the coil spring 88propels the plunger 70 forward (proximally). During a first operationalstage, the moving plunger 70 pushes the syringe 50 forward, such thatthe tip of the needle 55 projects from the first end 20 of the housing12. The initial biasing force provided by the first coil spring 88 issufficient to overcome the biasing force of the second coil spring 89 toallow movement of the syringe 50 against the backward biasing force ofthe second coil spring 89. In the first operational stage, the expandedregion 76 of the plunger 70, formed by the projecting elbows 78, restsagainst the second end 56 of the barrel portion 53, preventing theplunger 70 from traveling within the syringe barrel portion 53. In thismanner, all biasing force from the first coil spring 88 is applied tomove the syringe 50 forward towards the first end 20 of the device 10.

The activation means 320 illustrated in FIGS. 3-5 may have any suitablesize, shape, configuration and location suitable for releasing theplunger 70 or otherwise activating the device 10. For example, stillreferring to FIG. 2, the activation means 320 may be an activationbutton 32 formed on a distal end 30 of the housing 12, or may compriseanother suitable device, such as a latch, twist-activated switch andother devices known in the art. While the illustrative activation means320 is located towards a distal end 30 of the device 10, one skilled inthe art will recognize that the activation means 320 may be positionedin any suitable location on the device 10.

The forward motion of the syringe 50 towards the proximal end 20 of thedevice 10 continues against the biasing force of the coil spring 89until the flanged end 56 of the barrel portion 53 abuts a stop 123, suchas a protrusion or flange, on the housing 12, as shown in FIG. 4. Oneskilled in the art will recognize that alternate stopping or limitedmechanisms may be employed and that the invention is not limited to theillustrative stopping mechanism.

As shown in FIG. 4, the first operational stage propels the tip of theneedle 55 through the opening 28 at the first end 20 of the device 10,so that the needle 55 may pierce the skin of a patient. During thisstage, the syringe barrel portion 53 preferably remains sealed withoutexpelling the substance through the needle 55. The interference causedby the stopping mechanisms 56, 123 maintains the needle 55 in a selectedposition extending from the proximal open end 28 of the device 10 duringsubsequent steps. Until the stopping mechanisms 56, 123 stop themovement of the syringe 50, the compressible expanded central portion 76of the plunger 70 prevents movement of the plunger 70 relative to thebarrel portion 53.

The stops 56, 123 may be positioned at any suitable location relative tothe open first end 20 to allow the syringe 50 to penetrate the skin byany suitable depth suitable for an injection.

In the second operational stage, which commences after the stoppingmechanism 123 housing 12 catches the flanged portion 56, or otherstopping mechanism, stopping further movement of the barrel portion 53,the continued biasing force of the coil spring 88 continues to push theplunger 70 relative to the housing 12, as shown in FIG. 5. The biasingforce causes the elbows 78 of the plunger 70 to compress radially inwardand slide into the interior of the barrel portion 53. While theinterference between components 123 and 56 retains the barrel portion 53in a selected position (with the needle exposed) and with the elbows 78in a collapsed stage, the coil spring 88 pushes the plunger 70 withinthe barrel portion. After the plunger 70 overcomes the necessary forceto allow the elbows 78 to compress and extend into the barrel portion53, the plunger 70 applies pressure to the bung 54, causing ejection ofthe contents of the syringe 50 through the projecting needle 55. Becausethe first operational stage has displaced the needle 55 into the skin,the contents of the barrel portion 53 are injected directly into asubcutaneous region of the patient.

Referring to FIG. 6, in one embodiment of the invention, the automaticinjection device 10 may comprise two interlocking components: a syringehousing assembly 121 containing the proximal components of the device 10(e.g., the syringe barrel 53, coil spring 89, needle 55 and otherproximal components), and a firing mechanism assembly 122 containing thedistal components of the device (e.g., the means for actuating thesyringe). The syringe housing assembly 121 and the firing mechanismassembly 122 may be coupled through any suitable means. In theillustrative embodiment, a proximal end 122 a of the firing mechanismassembly 122 may be sized and configured to be inserted into a distalend 121 b of the syringe housing assembly 121. In addition, one or moretabs 127 (shown in detail in FIGS. 7, 8A-8C, and 9) on the proximal end122 a of the firing mechanism assembly 122 may snap-fit intocorresponding openings 126 on the distal end 121 b of the syringehousing assembly 122 to ensure alignment and coupling of the twoassemblies 121, 122 and the components housed therein.

FIG. 7 is an exploded view of the firing mechanism assembly 122according to an illustrative embodiment of the invention. As shown, thefiring mechanism assembly 122 includes the illustrative activationbutton 32, the illustrative actuator cap 34, an illustrative distalhousing component 12 b (firing body) and a coil spring 88 or otherbiasing mechanism. The illustrative firing mechanism assembly 122further includes a syringe actuator, illustrated as a syringe actuationcomponent 700, that extends from the proximal end 122 a of the distalhousing component 12 b for moving the syringe 50 in a first stage andactuating the syringe 50 to expel its contents in a second phase.

FIGS. 8A-8C illustrate the distal housing component 12 b, coil spring 88and syringe actuation component 700 when assembled without theactivation button 32. FIG. 9 is a perspective view of the distal housingcomponent 12 b and FIG. 10 is a perspective view of the syringeactuation component 700 according to illustrative embodiments of theinvention.

As shown in FIGS. 1-2 and 7-9, the distal housing component 12 bincludes a substantially tubular body, which may include contours 128 tofacilitate gripping of the device 10 by a user. A step 29 may be formedin a distal region 30 to facilitate seating of the actuator cap 34, asdescribed above. Forward of the step 29, the distal housing component 12b has a size and shape configured to be inserted into the distal end ofthe syringe housing 121. Tabs 127 are formed to facilitate couplingand/or locking of the two housing components 12 a and 12 b together. Asshown in FIG. 9, the tabs 127 may be formed in a depression 127 a on thesurface of the proximate end of the distal housing component 12 b, andmay also or alternatively include ribs 127 b for guiding the tabs into alocking position relative to the proximate housing component 12 a. Oneskilled in the art will recognize that any suitable means for couplingthe two assemblies together may be used and that the invention is notlimited to the illustrative coupling means.

As shown in FIGS. 2 and 8C, the distal housing component 12 b mayinclude an anchoring cap 12 c coupled to a smaller diameter distal endof the distal housing component 12 b for anchoring the firing mechanismsfor actuating the device 10 to the distal housing component 12 b. Theinterface of the anchoring cap 12 c and the distal housing component 12b may form a groove 1234 to facilitate a snap fit of the activationbutton 32 on the distal end of the distal housing component 12 b, or maybe joined by other suitable joining means as described above.

Referring to FIGS. 3 and 10, the syringe actuation component 700 ispreferably an integrated component formed of any suitable material, suchas an acetal-based plastic, though other suitable materials may also beused. The syringe actuation component 700 comprises a pressurizing end754 for applying pressure to the bung 54 of a corresponding syringe 50,a plunger rod portion 70 with a compressible expanded central portion,illustrated as the plunger elbows 78, as well as other components, suchas components for anchoring the coil spring 88 to the syringe actuationcomponent 700, as described below. The compressible expanded centralportion 76 facilitates movement of a corresponding syringe 50 into aprotracted position and expulsion of the contents of the syringe 50 intwo separate steps, as described above. Alternatively, the syringeactuator may comprise multiple actuators for moving and/or promotingexpulsion of the syringe 50.

The syringe actuation component 700 of FIGS. 2 and 10 further mayinclude an indicator 190 in a solid rod portion 70 distal from theelbows 78. During operation of the device 10 and after completion of aninjection, the indicator 190 is configured to align with the window 130on the housing 12 to indicate completion of the injection. The indicator190 preferably has a distinctive color or design to represent completionof an injection.

As shown in FIGS. 2, 7, 8C and 10, the illustrative syringe actuationcomponent 700 further includes a retaining flange 720 for holding theactuating coil spring 88 in a compressed position until actuation. Theretaining flange 720 is sized, dimensioned and formed of a material thatpreferably allows the syringe actuation component 700 to slidably andeasily move within the housing 12 when the device 10 is actuated.Extending distally from the retaining flange 720, the syringe actuationcomponent 700 forms a base 788 for the actuating coil spring 88. Thebase 788 terminates in a trigger anchoring portion 789. The illustrativebase 788 may comprise flexible legs 788 a, 788 b around which the spring88 coils. The trigger anchoring portion 789 may comprise tabbed feet7891 extending from the base 788 and configured to selectively engagethe anchoring cap 12 c and/or distal housing component 12 b. Theactivation button 32 coupled to the distal end of the distal housingcomponent 12 b is configured to hold the trigger anchoring portion 789until activation. When activated, the activation button 32 releases thetrigger anchoring portion 789, allowing the coil spring 88 to propel thesyringe actuation component 700 towards the proximal end 20 of thedevice 10 in an operation described above.

In a retracted, anchored position shown FIGS. 2, 8C and 10(corresponding to the schematic of FIG. 3), the trigger anchoringportion 789 interacts with the housing 12, which holds the tabbed feet7891 in a latched position, against the biasing force of the coil spring88, to maintain the syringe actuation component 700 in a retractedposition. In this position, the flange 720 retracts the spring 88against the back, distal wall 712 of the distal housing component 12 b.An opening 713 in the anchoring cap 12 c allows the activation button 32access to the anchoring portion 789. In the retracted position, thepressurizer 754 of the syringe actuation component 700 extends out of anopening 228 on the proximal end 122 a of the distal housing component 12b. When the distal housing component 12 b couples to a correspondingsyringe actuation mechanism 121, the pressurizer 754 extends into thebarrel portion of a syringe housed therein. The pressurizer 754 may beintegral with, the same as, connected to, or otherwise in communicationwith the bung 54 of a syringe 50 housed in the device 10 and may haveany suitable size, shape and configuration suitable for applyingpressure to the bung 54. In one embodiment, the pressurizer 754 has across-section corresponding to the shape of the barrel portion 53 of acorresponding syringe 50 so as to substantially seal the barrel portion53, and the pressurizer 754 is configured to slidably move within thebarrel portion 53 to apply pressure to the bung 54 and actuate thesyringe 50.

In the illustrative embodiment of FIGS. 7-10, the syringe actuationcomponent 700 constitutes a single, integrated mechanism for anchoring acorresponding syringe 50, spring 88 and other components, actuating andmoving the syringe 50 to a protracted position, and separately expellingthe contents of the syringe 50.

FIG. 11 is an exploded view of the syringe housing assembly 121 of anillustrative embodiment of the invention, which is configured to coupleto and interact with the firing mechanism assembly 122 of FIGS. 7-10.The illustrative syringe housing assembly 121 includes a proximalhousing component 12 a, the proximate cap 24, a proximal, second biasingmechanism 89, a syringe carrier 500 and a stepped shroud 12 d forming aproximate portion 20 of the housing 12 when assembled and includes theproximate opening 28, as also shown in FIG. 2. The components 12 a, 12d, 89, 500 and 24 cooperate to house a syringe 50 containing a substanceto be injected and facilitate operation of the device 10 in the twodifferent operational stages as described above.

Illustrative embodiments of the syringe carrier 500, the stepped shroud12 d and the proximate cap 24 are shown in detail in FIGS. 12, 13 and14, respectively. FIGS. 15 a and 15 b are a perspective side view and across-sectional side view, respectively, of the assembled spring housingassembly 121 according to one embodiment of the invention. One skilledin the art will recognize that the invention is not limited to theillustrative embodiments.

Referring now to FIGS. 1, 2, 11, 12 and 15 b, the syringe carrier 500 ofthe illustrative embodiment envelopes the distal half of a syringe 50used in the device 10. The syringe 50 rests in the carrier 500, and bothare contained in the housing 12. During operation, the syringe 50 andcarrier 500 move forward (e.g., proximally) within the housing 12. Thehousing 12 stops and limits the movement of the carrier 500, and thecarrier 500 in turn stops and limits the movement of the syringe 50. Theillustrative syringe carrier 500 has a substantially tubular structureincluding window cutouts 501 preferably aligned with the window 130 onthe housing 12 a to allow a user to view the contents of the syringe 50prior to operation. The syringe carrier 500 may include a flanged distalend 562 configured to interface with a flanged distal end 56 (shown inFIGS. 3 and 15 b) of the syringe 50. The flanged distal end 562 mayserve as a damper for the syringe 50. The syringe carrier 500 mayfurther include an intermediate flange 563, which in the illustrativeembodiment forms a stop for the syringe 50 that interacts with aninterior stop 256 (shown in FIG. 15 b) on the proximate housingcomponent 12 a to limit forward motion of the syringe 50. Theillustrative syringe carrier 500 may further include a proximate anchorportion 503 that limits movement of the syringe 50 in a distal, rearwarddirection. In the illustrative embodiment, the proximate anchor portion503 includes a radial groove configured to engage the interior stop 256.A syringe carrier coupler 504 extends forward past the proximate anchorportion 503 to facilitate coupling of the syringe carrier 500 with thedistal end of the spring 89 and the stepped shroud 12 d, as shown inFIG. 15 b. In one embodiment, the syringe carrier 500 is stationarywithin the housing 12 and the syringe 50 selectively and controllablyslides within and relative to the syringe carrier 500. Alternatively,the syringe carrier 500 is slidably disposed within the housing 12 andselectively carries the syringe 50 within the housing 12. The syringecarrier 500 may have any suitable configuration and size suitable forcarrying or guiding the syringe 50 within the housing 12.

Referring to FIGS. 13 and 15 b, the illustrative stepped shroud 12 dforms a proximate end 20 of the housing 12. The illustrative steppedshroud 12 d has a substantially tubular body, including a proximate boss112 defining the proximate opening 28 of the device 10, through whichthe syringe needle 55 projects during operation of the device 10. A step113 from the main tubular body portion 116 forms the proximate boss 112of smaller diameter than the main tubular body portion 116 of thestepped shroud 12 d. As shown in FIG. 15 b, the step 113 forms a forwardstop for the spring 89 to confine the spring 89 and prevent forwardmovement of the spring 89 towards the proximate end 20 of the device 10.In the illustrative embodiment, shown in FIG. 15 b, the distal rim 115of the stepped shroud 12 d abuts the proximate side of the stop 256 ofthe proximal housing component 12 a. Referring now to FIG. 13, distalarms 114 extend from the stepped shroud 12 d to lock in the steppedshroud 12 d to prevent accidental needle sticks.

Referring to FIGS. 14, 15 a and 15 b, the interior of the illustrativecap 24 may include a plurality of radial grooves 241, 243 for receivingprotruding portions of the stepped shroud 12 d and the proximal housingcomponent 12 a. For example, as best illustrated in FIG. 15 b, a firstradially outer groove 241 receives a proximate end of the sidewall 242of the proximal housing component 12 a. A second, radially inner groove243 receives the proximate end of the boss 112. The cap boss 26 extendsinto the inner lumen 1012 of the housing 12 and surround the proximalend of a syringe 50 loaded therein when the cap 24 is coupled to thehousing 12. In an embodiment, an interior needle cover 246 (shown inFIG. 15 b) of the cap 24 sheaths the syringe needle 55. When the cap 24is removed, the syringe needle 55 is exposed within the lumen 1012 ofthe housing 12. The cap 24 may also include an opening in a proximal end248 thereof.

As described above and shown in FIG. 15 a, openings 126 in the proximalhousing component 12 a receive tabs 127 of the firing mechanism assembly122 to facilitate assembly of the device 10. The window 130 describedabove for allowing a user to view the contents of a syringe contained inthe assembly 121, as well as to view an indicator 190 that fills thewindow 130 after completion of an injection may be formed in theproximal housing component 12 a.

FIGS. 16A and 16B are cross-sectional views at 90 degree offset anglesfrom each other, illustrating an assembled automatic injection device10, wherein the syringe housing assembly 121 and a firing mechanismassembly 122 are coupled together, such that the pressurizer 754 of thesyringe actuation component 700 extends into the barrel portion 53 of asyringe 50 housed in the syringe housing assembly 121 and incommunication with a bung 54 of the syringe 50.

As shown, in FIG. 16 b the trigger anchoring portion 789 of the syringeactuation component 700 is anchored towards the distal end of thehousing 12 by the activation button 32. When a user depresses theactivation button 32, driving arms 32 a connected to the activationbutton 32 compress the tabbed feet 7891 of the trigger anchoring portion789, releasing the syringe actuation mechanism 700 and releasing thespring 88. Prior to operation, the compressible expanded central portion76, illustrated as elbows 78, of the syringe actuation component 700rests above the flange 56 of the syringe 50 to allow the compressibleexpanded central portion 76, when pushed by a released coil spring 88,to apply pressure to the syringe barrel portion 53, thereby moving thesyringe 50 forward within the housing 12 when actuated. As describedabove, once a stop, such as a stop 256 on the proximal housing component12 a shown in FIG. 15 b and FIG. 16 a, catches the syringe and haltsadditional forward motion of the projecting syringe 50, the continuedbiasing force on the spring 88 will continue to move the syringeactuation component 700 forward, causing the compressible expandedcentral portion 76 to compress and move into the barrel portion 53 ofthe syringe 50. The forward motion of the syringe actuation component700 within the barrel portion 53 causes the pressurizer 754 to applypressure to the bung 54, causing expulsion of the syringe contents intoan injection site.

As also shown in FIGS. 16 a and 16 b, the actuator cap 34 may include astabilizing protrusion 340 that extends through the activator button 32and between the feet tabbed 7891 of the syringe actuation component 700to stabilize the components of the device prior to activation.

FIG. 17 is a detailed view of the interface between a syringe housingassembly 121 and a firing mechanism assembly 122 (referring to FIGS. 6and 8 a) of an automatic injection device 10 of an embodiment of theinvention, illustrating the indicator 190 of the syringe actuationcomponent 700 according to one embodiment of the invention. Theindicator 190 may have a distinctive color and/or design to indicate toa user that an injection is complete. Also referring to FIG. 2, theindicator 190 is configured to align with the window 130 of the housing12 after the syringe actuation component 700, with the compressibleexpanded central portion 76 collapsed and moved forward within thebarrel portion 53, completes an injection and fully or substantiallyfully expels the contents of the syringe 50 out of the needle 55 andinto a patient. Thus, prior to operation of the device 10, the syringebarrel 53 aligns with the window 130 and the contents are viewabletherein. After injection, with the syringe barrel portion 53 has movedtowards the proximal end 20 of the device 10, such that the needle 55protrudes from the proximal end 20 into an injection site, and thesyringe actuation component 700 has moved forward within the syringebarrel portion 53, the indicator 190 aligns with the window 130 toindicate completion of an injection. Therefore, even if the first stageof operation (movement of the syringe 50 into an exposed position withthe needle 55 protruding) is complete, the indicator 190 will not alignwith the window 130 or otherwise indicate completion of an injectionuntil the syringe actuation component 700 has pushed the contents of thesyringe 50 out of the barrel 53.

FIGS. 18-22 are cross-sectional views of an assembled automaticinjection device 10′ according to an illustrative embodiment of theinvention. The illustrative embodiment of the automatic injection device10′ includes two mating proximal and distal housing components 12 a, 12b. The proximal and distal housing components 12 a, 12 b mate to form acomplete housing 12. As shown, a proximal housing component 12 a,forming a proximal end of the housing 12, receives a proximal end of thedistal housing components 12 b. A cooperating projection 312 and groove313, or a plurality of cooperating projections 312 and grooves 313,facilitate mating of the proximal and distal housing components 12 a, 12b in the illustrative embodiment. Other suitable mating mechanisms mayalternatively be employed. A shelf 29 formed on an outer surface of thedistal housing component 12 b may form a stop for the second removablecap 34.

As shown, the activation button 32′ may be a cap covering the distal endof the distal housing component 12 b. The illustrative activation button32′ slides relative to the distal housing component 12 b to actuate asyringe actuator, such as the plunger 70 or syringe actuation component700. A shelf/step 138 formed on the outer surface of the distal housingcomponent 12 b near the distal end 30 of the distal housing component 12b allows for and limits the movement of the activation button 32′relative to the housing 12, as shown in FIGS. 20 and 22. Theillustrative activation button 32′ releasably retains flexible anchoringarms 172 of the plunger 70′. When depressed, the activation button 32′releases the flexible anchoring arms 172 to allow a first biasingmechanism, illustrated as spring 88′ to propel the plunger 70′ towardsthe proximal end of the device 10′.

In the embodiment of FIGS. 18-22, the plunger 70′ further includes aflange 72′ located between the compressible extended middle portion 78and the distal end of the plunger rod 71′. A first biasing mechanism 88′is seated between an interior distal end of the housing 12 and theflange 72′ to bias the plunger 70 towards the proximal end of thehousing 12′. As described above, when the activation button 34′ releasesthe anchoring arms 172, the coil spring 88′, or other suitable biasingmechanism propels the plunger 70′ towards the proximal end 20 of thedevice 10. The illustrative embodiment 10′ further includes an indicator190 formed at an intermediate portion of the plunger rod 71′ between theflange 72′ and the compressible extended portion 76, illustrated asflexible elbows 78′.

The syringe 50′ of FIGS. 18-22 may include protrusions or other suitablecomponent to facilitate controlled movement of the syringe within thehousing 12′. For example, with reference to FIG. 18, the syringe 50′includes a sleeve 157 forming a proximal protrusion 158 for abutting aproximal side of a first protrusion 168 formed on an inner surface ofthe housing 12′ for limited movement of the syringe 50′ in the distaldirection within the housing 12′. The sleeve 157 may also form a flange159 that may abut the distal side of the first protrusion 168 to limitmovement of the syringe 50′ in the proximal direction during aninjection.

In the embodiment of FIGS. 18-22, the second biasing mechanism,illustrated as coil spring 89′ is disposed about a proximal portion ofthe syringe 50′. A shelf 169 formed at a proximal inner surface of thehousing 12′ receives a proximal end of the coil spring 89′. Referring toFIG. 19, the proximal protrusion 158 of the syringe sleeve 157, oranother suitably disposed mechanism, receives the distal end of the coilspring 89′. As described above, the second biasing mechanism 89′ biasesthe syringe 50′ in a retracted position within the housing 12′ untilactivation of the device 10.

As shown in FIGS. 18-22, the automatic injection device 10′ incorporatesan indicator 190 to indicate to the user of the device 10 when the dosefrom the syringe 50 has been fully or substantially fully ejected. Inthe illustrative embodiment, the indicator 190 is formed on a portion ofthe plunger rod 71′ between the compressible expanded central portion 76and the flange 72′. As the plunger rod 71 moves during operation, theindicator 190 advances towards and aligns with window 130 as the doseempties from the syringe. The indicator 190, which is preferably adifferent color or pattern from the substance being injected, fills thewindow 130 entirely to indicate that the dosage has been ejected. Anysuitable indicator may be used.

After injection of the dose from the device 10 via the needle 55, aneedle sheath 112, which may be formed by the proximal end 20 of theshroud 12 d may automatically advance over the exposed needle 55extending from the housing proximal end 20 to prevent accidental sticks.

Referring to FIG. 23, the illustrative housing 12 includes a window 130formed through a side wall of the housing 12 to allow a user to view thecontents of the syringe.

The illustrative window 130 preferably has a keyhole shape. For example,the window 130 includes a first end 132 that is substantially linear,and may include a curved inner edge 132 a. The second end 134 of thewindow 130 may be substantially hemispherical in shape and wider thanthe first end 132 of the window 130. The window 130 may include a fillline 135 to allow verification of the proper dosage within the syringe.

According to one embodiment of the invention, the illustrative automaticinjection device may be used to deliver a dose of a TNF inhibitor usedto treat arthritis and other diseases. In one embodiment, the solutioncontained in the syringe 50 or 50′ contains 40 milligrams of drugproduct (TNFα blocker or inhibitor), 1 mL of adalimumab: 40 mgadalimumab, 4.93 mg sodium chloride, 0.69 mg monobasic sodium phosphatedehydrate, 1.22 mg dibasic sodium phosphate dehydrate, 0.24 mg sodiumcitrate, 1.04 mg citric acid monohydrate, 9.6 mg mannitol, 0.8 mgpolysorbate 50 and water for injection, with USP sodium hydroxide addedas necessary to adjust pH to be about 5.2.

FIG. 24 illustrates use of the device to deliver a dosage of asubstance, such as a TNF inhibitor, to a subcutaneous region of a useraccording to an illustrative embodiment of the invention. In a firststep, a pre-loaded automatic injection device, such as the device 10 ordevice 10′ described above, is provided to a user. Next, the userselects and prepares an injection site 400 for receiving the substancein a subcutaneous region. For example, the user may clean the injectionsite using a suitable cleaning device, such as an alcohol preparationpad, which may be integrated with the device 10 or 10′ of the presentinvention. Following the preparation, the user prepares the dose forinjection. For example, the user may examine the solution through thewindow 130 to ensure that the solution has a proper color andconsistency and that the level of the liquid is at the fill line toensure proper dosage. After ensuring proper dosage and contents in thepre-filled syringe 50, the user then removes the first cap 24 and secondcap 34 of the device 10 or 10′ to expose the opening 28 on the first end20 and the activation button 32 on the second end 30. Then, the userplaces the automatic injection device 10 or 10′ with the open first end20 adjacent or proximal to the injection site. The user may squeeze theskin in this area to facilitate injection. The automatic injectiondevice 10 or 10′ is preferably held at about a ninety-degree angle tothe body of the user, flush against the skin, as shown in FIG. 24. Afterplacement, the user presses the activation button 32 to initiate aninjection. The depression of the activation button may effect an audibleindicator (noise), such as a “click” to indicate initiation of theinjection. As described above, depression of the activation button 32causes the activation button to release the anchor, such as the anchorend 789 of the syringe actuation component 700, allowing a biasingspring 88 to propel the syringe actuation component 700, and thus, thesyringe 50 towards the proximal end 20 of the device 10 or 10′. Afterthe syringe 50 pierces the skin, or otherwise enters an administrationsite, the syringe 50 forward movement stops, which the syringe actuatormechanism, or other mechanism, then pushes on the syringe bung 54 toexpel the contents of the syringe 50. The user maintains the automaticinjection device 10 or 10′ in the position shown in FIG. 24 for apredetermined time period. If an indicator 190 is provided in theautomatic injection device 10, the user maintains the automatic injectordevice 10 in position until the indicator 190 fills the window 130indicating that a full or substantially full dose of the substance hasbeen injected. Afterwards, the user removes the device 100 to pull theneedle 55 out of the skin. The needle 55 is preferably automaticallysheathed to prevent accidental pricks. The user may then dispose of theempty automatic injection device 10 or 10′.

According to another embodiment of the invention, a training automaticinjection device may be provided for training users how to use theautomatic injection device 10 or 10′. The illustrative traininginjection device mimics the functionality of the automatic trainingdevice 10 or 10′ without injecting a substance into a patient. Thetraining automatic injection device may have substantially similarcomponents as the automatic injection devices 10, 10′ described above,yet lacks a needle and/or a drug. For example, the training automaticinjection device may be filled with air that is expelled from thesyringe barrel portion 53 when activated. The operation of the trainingautomatic injection device advances the syringe and expels the air orother benign substance, preferably without penetrating the skin of theuser. The training automatic injection device preferably includes anindicator, such as indicator 190. The training automatic injectiondevice may help train user to become accustomed to toe handling, sound,feel, operation, use of the indicator 190 and/or timing of the automaticinjection device without wasting valuable resources.

The present invention provides significant advantages over prior methodsfor administering drugs, particularly TNFα inhibitors. For example, theautomatic injection device enhances administration, convenience, is lesspainful, includes a hidden needle to remove apprehension and anxiety forpatients who are “needle phobic” to one degree or another so that fearis not a factor. In addition, the automatic injection device efficientlydelivers a drug or other substance while being safe. The automaticinjection device of the invention also offers safety advantages. Unliketraditional syringes, there is no needle exposure with the automaticinjection device. The automatic injection device contains a white needlesleeve that surrounds the needle and protects patients from needlestickinjury before and after use. Also, a safety cap on the automaticinjection device prevents accidental misfiring, a potential occurrencewith prefilled syringes. An audible “click” announces the beginning ofthe injection, and a distinctive indicator in the inspection windowshows the patient that the complete dose was fully administered.

Examples of uses of the automatic injection device of the invention alsoare described in detail in U.S. Provisional Application Ser. No.60/818,231, which is expressly incorporated herein by reference in itsentirety. Other examples of automatic injection devices are described inPCT/EP2005/002487, which is expressly incorporated herein by referencein its entirety. U.S. Design patent applications Ser. Nos. 29/265,691and 29/265,646 also describe automatic injection devices, which are alsoeach incorporated herein by reference.

III. TNFα Inhibitors for Use in Compositions and Methods of Invention

The present invention can be used to administer a dose of a substance,such as a liquid drug, e.g., a TNFα inhibitor, to a user (also referredto herein as a patient). In one embodiment, the dose delivered by theautomatic injection device of the invention comprises a human TNFαantibody, or antigen-binding portion thereof. A particularly preferredmedication is a TNFα inhibitor.

The term “human TNFα” (abbreviated herein as hTNFα, or simply hTNF), asused herein, is intended to refer to a human cytokine that exists as a17 kD secreted form and a 26 kD membrane associated form, thebiologically active form of which is composed of a trimer ofnoncovalently bound 17 kD molecules. The structure of hTNFα is describedfurther in, for example, Pennica, D., et al. (1984) Nature 312:724-729;Davis, J. M., et al. (1987) Biochemistry 26:1322-1326; and Jones, E. Y.,et al. (1989) Nature 338:225-228. The term human TNFα is intended toinclude recombinant human TNFα (rhTNFα), which can be prepared bystandard recombinant expression methods or purchased commercially (R & DSystems, Catalog No. 210-TA, Minneapolis, Minn.). TNFα is also referredto as TNF.

The term “TNFα inhibitor” refers to an agent that interferes with TNFαactivity. The term also includes each of the anti-TNFα human antibodies(used interchangeably herein with TNFα antibodies) and antibody portionsdescribed herein as well as those described in U.S. Pat. Nos. 6,090,382;6,258,562; 6,509,015, and in U.S. patent application Ser. Nos.09/801,185 and 10/302,356. In one embodiment, the TNFα inhibitor used inthe invention is an anti-TNFα antibody, or a fragment thereof, includinginfliximab (Remicade®, Johnson and Johnson; described in U.S. Pat. No.5,656,272, incorporated by reference herein), CDP571 (a humanizedmonoclonal anti-TNF-alpha IgG4 antibody), CDP 870 (a humanizedmonoclonal anti-TNF-alpha antibody fragment), an anti-TNF dAb (Peptech),CNTO 148 (golimumab; Medarex and Centocor, see WO 02/12502), andadalimumab (HUMIRA® Abbott Laboratories, a human anti-TNF mAb, describedin U.S. Pat. No. 6,090,382 as D2E7). Additional TNF antibodies that maybe used in the invention are described in U.S. Pat. Nos. 6,593,458;6,498,237; 6,451,983; and 6,448,380, each of which is incorporated byreference herein. In another embodiment, the TNFα inhibitor is a TNFfusion protein, e.g., etanercept (Enbrel®, Amgen; described in WO91/03553 and WO 09/406476, incorporated by reference herein). In anotherembodiment, the TNFα inhibitor is a recombinant TNF binding protein(r-TBP-I) (Serono).

The term “antibody”, as used herein, is intended to refer toimmunoglobulin molecules comprised of four polypeptide chains, two heavy(H) chains and two light (L) chains inter-connected by disulfide bonds.Each heavy chain is comprised of a heavy chain variable region(abbreviated herein as HCVR or VH) and a heavy chain constant region.The heavy chain constant region is comprised of three domains, CH1, CH2and CH3. Each light chain is comprised of a light chain variable region(abbreviated herein as LCVR or VL) and a light chain constant region.The light chain constant region is comprised of one domain, CL. The VHand VL regions can be further subdivided into regions ofhypervariability, termed complementarity determining regions (CDR),interspersed with regions that are more conserved, termed frameworkregions (FR). Each VH and VL is composed of three CDRs and four FRs,arranged from amino-terminus to carboxy-terminus in the following order:FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. The antibodies of the inventionare described in further detail in U.S. Pat. Nos. 6,090,382; 6,258,562;and 6,509,015, each of which is incorporated herein by reference in itsentirety.

The term “antigen-binding portion” of an antibody (or simply “antibodyportion”), as used herein, refers to one or more fragments of anantibody that retain the ability to specifically bind to an antigen(e.g., hTNFα). It has been shown that fragments of a full-lengthantibody can perform the antigen-binding function of an antibody.Examples of binding fragments encompassed within the term“antigen-binding portion” of an antibody include (i) a Fab fragment, amonovalent fragment consisting of the VL, VH, CL and CH1 domains; (ii) aF(ab′)₂ fragment, a bivalent fragment comprising two Fab fragmentslinked by a disulfide bridge at the hinge region; (iii) a Fd fragmentconsisting of the VH and CH1 domains; (iv) a Fv fragment consisting ofthe VL and VH domains of a single arm of an antibody, (v) a dAb fragment(Ward et al. (1989) Nature 341:544-546), which consists of a VH or VLdomain; (vi) an isolated complementarity determining region (CDR); and(vii) a dual variable domain (DVD) antibody. Furthermore, although thetwo domains of the Fv fragment, VL and VH, are coded for by separategenes, they can be joined, using recombinant methods, by a syntheticlinker that enables them to be made as a single protein chain in whichthe VL and VH regions pair to form monovalent molecules (known as singlechain Fv (scFv); see e.g., Bird et al. (1988) Science 242:423-426; andHuston et al. (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883). Suchsingle chain antibodies are also encompassed within the term“antigen-binding portion” of an antibody. Other forms of single chainantibodies, such as diabodies are also encompassed. Diabodies arebivalent, bispecific antibodies in which VH and VL domains are expressedon a single polypeptide chain, but using a linker that is too short toallow for pairing between the two domains on the same chain, therebyforcing the domains to pair with complementary domains of another chainand creating two antigen binding sites (see e.g., Holliger et al. (1993)Proc. Natl. Acad. Sci. USA 90:6444-6448; Poljak et al. (1994) Structure2:1121-1123). The antibody portions of the invention are described infurther detail in U.S. Pat. Nos. 6,090,382, 6,258,562, 6,509,015, eachof which is incorporated herein by reference in its entirety.

In one embodiment, the TNF inhibitor used in the methods andcompositions of the invention includes a TNF fusion protein, e.g.,etanercept (Enbrel®, Amgen; described in WO 91/03553 and WO 09/406476,incorporated by reference herein), as well as a recombinant TNF bindingprotein (r-TBP-I) (Serono).

In one embodiment, the TNF inhibitor used in the methods andcompositions of the invention includes isolated human antibodies, orantigen-binding portions thereof, that bind to human TNFα with highaffinity and a low off rate, and have a high neutralizing capacity.Preferably, the human antibodies of the invention are recombinant,neutralizing human anti-hTNFα antibodies. The most preferredrecombinant, neutralizing antibody of the invention is referred toherein as D2E7, also referred to as HUMIRA® or adalimumab (the aminoacid sequence of the D2E7 VL region is shown in SEQ ID NO: 1 of U.S.Pat. No. 6,090,382 the amino acid sequence of the D2E7 VH region isshown in SEQ ID NO: 2 of U.S. Pat. No. 6,090,382). The properties ofD2E7 (HUMIRA®) have been described in Salfeld et al., U.S. Pat. Nos.6,090,382, 6,258,562, and 6,509,015, which are each incorporated byreference herein. Other examples of TNFα inhibitors include chimeric andhumanized murine anti-hTNFα antibodies that have undergone clinicaltesting for treatment of rheumatoid arthritis (see e.g., Elliott et al.(1994) Lancet 344:1125-1127; Elliot et al. (1994) Lancet 344:1105-1110;Rankin et al. (1995) Br. J. Rheumatol. 34:334-342). In anotherembodiment, the TNFα inhibitor used in the invention is an anti-TNFαantibody, or a fragment thereof, comprising infliximab (Remicade®,Johnson and Johnson; described in U.S. Pat. No. 5,656,272, incorporatedby reference herein), CDP571 (a humanized monoclonal anti-TNF-alpha IgG4antibody), CDP 870 (a humanized monoclonal anti-TNF-alpha antibodyfragment), an anti-TNF dAb (Peptech), and CNTO 148 (golimumab; Medarexand Centocor, see WO 02/12502).

The term “recombinant human antibody”, as used herein, is intended toinclude all human antibodies that are prepared, expressed, created orisolated by recombinant means, such as antibodies expressed using arecombinant expression vector transfected into a host cell (describedfurther below), antibodies isolated from a recombinant, combinatorialhuman antibody library (described further below), antibodies isolatedfrom an animal (e.g., a mouse) that is transgenic for humanimmunoglobulin genes (see e.g., Taylor et al. (1992) Nucl. Acids Res.20:6287) or antibodies prepared, expressed, created or isolated by anyother means that involves splicing of human immunoglobulin genesequences to other DNA sequences. Such recombinant human antibodies havevariable and constant regions derived from human germ lineimmunoglobulin sequences. In certain embodiments, however, suchrecombinant human antibodies are subjected to in vitro mutagenesis (or,when an animal transgenic for human Ig sequences is used, in vivosomatic mutagenesis) and thus the amino acid sequences of the VH and VLregions of the recombinant antibodies are sequences that, while derivedfrom and related to human germ line VH and VL sequences, may notnaturally exist within the human antibody germ line repertoire in vivo.

Such chimeric, humanized, human, and dual specific antibodies can beproduced by recombinant DNA techniques known in the art, for exampleusing methods described in PCT International Application No.PCT/US86/02269; European Patent Application No. 184,187; European PatentApplication No. 171,496; European Patent Application No. 173,494; PCTInternational Publication No. WO 86/01533; U.S. Pat. No. 4,816,567;European Patent Application No. 125,023; Better et al. (1988) Science240:1041-1043; Liu et al. (1987) Proc. Natl. Acad. Sci. USA84:3439-3443; Liu et al. (1987) J. Immunol. 139:3521-3526; Sun et al.(1987) Proc. Natl. Acad. Sci. USA 84:214-218; Nishimura et al. (1987)Cancer Res. 47:999-1005; Wood et al. (1985) Nature 314:446-449; Shaw etal. (1988) J. Natl. Cancer Inst. 80:1553-1559; Morrison (1985) Science229:1202-1207; Oi et al. (1986) BioTechniques 4:214; U.S. Pat. No.5,225,539; Jones et al. (1986) Nature 321:552-525; Verhoeyan et al.(1988) Science 239:1534; and Beidler et al. (1988) J. Immunol.141:4053-4060, Queen et al., Proc. Natl. Acad. Sci. USA 86:10029-10033(1989), U.S. Pat. No. 5,530,101, U.S. Pat. No. 5,585,089, U.S. Pat. No.5,693,761, U.S. Pat. No. 5,693,762, Selick et al., WO 90/07861, andWinter, U.S. Pat. No. 5,225,539.

An “isolated antibody”, as used herein, is intended to refer to anantibody that is substantially free of other antibodies having differentantigenic specificities (e.g., an isolated antibody that specificallybinds hTNFα is substantially free of antibodies that specifically bindantigens other than hTNFα). An isolated antibody that specifically bindshTNFα may, however, have cross-reactivity to other antigens, such asTNFα molecules from other species. Moreover, an isolated antibody may besubstantially free of other cellular material and/or chemicals.

A “neutralizing antibody”, as used herein (or an “antibody thatneutralized hTNFα activity”), is intended to refer to an antibody whosebinding to hTNFα results in inhibition of the biological activity ofhTNFα. This inhibition of the biological activity of hTNFα can beassessed by measuring one or more indicators of hTNFα biologicalactivity, such as hTNFα-induced cytotoxicity (either in vitro or invivo), hTNFα-induced cellular activation and hTNFα binding to hTNFαreceptors. These indicators of hTNFα biological activity can be assessedby one or more of several standard in vitro or in vivo assays known inthe art (see U.S. Pat. No. 6,090,382). Preferably, the ability of anantibody to neutralize hTNFα activity is assessed by inhibition ofhTNFα-induced cytotoxicity of L929 cells. As an additional oralternative parameter of hTNFα activity, the ability of an antibody toinhibit hTNFα-induced expression of ELAM-1 on HUVEC, as a measure ofhTNFα-induced cellular activation, can be assessed.

The term “surface plasmon resonance”, as used herein, refers to anoptical phenomenon that allows for the analysis of real-time biospecificinteractions by detection of alterations in protein concentrationswithin a biosensor matrix, for example using the BIAcore system(Pharmacia Biosensor AB, Uppsala, Sweden and Piscataway, N.J.). Forfurther descriptions, see Example 1 of U.S. Pat. No. 6,258,562 andJonsson et al. (1993) Ann. Biol. Clin. 51:19; Jönsson et al. (1991)Biotechniques 11:620-627; Johnsson et al. (1995) J. Mol. Recognit.8:125; and Johnnson et al. (1991) Anal. Biochem. 198:268.

The term “K_(off)”, as used herein, is intended to refer to the off rateconstant for dissociation of an antibody from the antibody/antigencomplex.

The term “K_(d)”, as used herein, is intended to refer to thedissociation constant of a particular antibody-antigen interaction.

The term “IC₅₀” as used herein, is intended to refer to theconcentration of the inhibitor required to inhibit the biologicalendpoint of interest, e.g., neutralize cytotoxicity activity.

The term “dose,” as used herein, refers to an amount of a substance,such as a TNFα inhibitor, which is administered to a user preferablyusing the automatic injection device of the invention. In oneembodiment, the dose comprises an effective amount, for example,including 20 mg, 40 mg, 80 mg, and 160 mg, of the TNFα inhibitoradalimumab.

The term “dosing”, as used herein, refers to the administration of asubstance (e.g., an anti-TNFα antibody) to achieve a therapeuticobjective (e.g., treatment of rheumatoid arthritis).

A “dosing regimen” describes a treatment schedule for a substance, suchas a TNFα inhibitor, e.g., a treatment schedule over a prolonged periodof time and/or throughout the course of treatment, e.g. administering afirst dose of a TNFα inhibitor at week 0 followed by a second dose of aTNFα inhibitor on a biweekly dosing regimen.

The terms “biweekly dosing regimen”, “biweekly dosing”, and “biweeklyadministration”, as used herein, refer to the time course ofadministering a substance (e.g., an anti-TNFα antibody) to a patient toachieve a therapeutic objective, e.g., throughout the course oftreatment. The biweekly dosing regimen is not intended to include aweekly dosing regimen. Preferably, the substance is administered every9-19 days, more preferably, every 11-17 days, even more preferably,every 13-15 days, and most preferably, every 14 days. In one embodiment,the biweekly dosing regimen is initiated in a patient at week 0 oftreatment. In another embodiment, a maintenance dose is administered ona biweekly dosing regimen. In one embodiment, both the loading andmaintenance doses are administered according to a biweekly dosingregimen. In one embodiment, biweekly dosing includes a dosing regimenwherein doses of a TNFα inhibitor are administered to a patient everyother week beginning at week 0. In one embodiment, biweekly dosingincludes a dosing regimen where doses of a TNFα inhibitor areadministered to a patient every other week consecutively for a giventime period, e.g., 4 weeks, 8 weeks, 16, weeks, 24 weeks, 26 weeks, 32weeks, 36 weeks, 42 weeks, 48 weeks, 52 weeks, 56 weeks, etc. Biweeklydosing methods are also described in US 20030235585, incorporated byreference herein.

The term “combination” as in the phrase “a first agent in combinationwith a second agent” includes co-administration of a first agent and asecond agent, which for example may be dissolved or intermixed in thesame pharmaceutically acceptable carrier, or administration of a firstagent, followed by the second agent, or administration of the secondagent, followed by the first agent.

The term “concomitant” as in the phrase “concomitant therapeutictreatment” includes administering an agent in the presence of a secondagent. A concomitant therapeutic treatment method includes methods inwhich the first, second, third, or additional substances areco-administered. A concomitant therapeutic treatment method alsoincludes methods in which the first or additional agents areadministered in the presence of a second or additional substances,wherein the second or additional agents, for example, may have beenpreviously administered. A concomitant therapeutic treatment method maybe executed step-wise by different patients. For example, one subjectmay administer to a user a first agent and a second subject may toadministered to the user a second substance, and the administering stepsmay be executed at the same time, or nearly the same time, or at distanttimes, so long as the first substance (and additional substances) areafter administration in the presence of the second substance (andadditional substances). The actor and the user may be the same entity(e.g., human).

The term “combination therapy”, as used herein, refers to theadministration of two or more therapeutic substances, e.g., an anti-TNFαantibody and another drug. The other drug(s) may be administeredconcomitant with, prior to, or following the administration of ananti-TNFα antibody.

The term “treatment,” as used within the context of the presentinvention, is meant to include therapeutic treatment, as well asprophylactic or suppressive measures, for the treatment of a disorder,such as a disorder in which TNFα is detrimental, e.g., rheumatoidarthritis.

In one embodiment, the invention provides improved uses and compositionsfor treating a disorder in which TNFα is detrimental, e.g., rheumatoidarthritis with a TNFα inhibitor, e.g., a human TNFα antibody, or anantigen-binding portion thereof, through an automatic injection device.

The substance that is delivered via the automatic injection device ofthe invention may be a TNFα inhibitor. A TNFα inhibitor includes anyagent (or substance) that interferes with TNFα activity. In a preferredembodiment, the TNFα inhibitor can neutralize TNFα activity,particularly detrimental TNFα activity which is associated withdisorders in which TNFα activity is detrimental, including, but notlimited to, rheumatoid arthritis, juvenile rheumatoid arthritis,ankylosing spondylitis, Crohn's disease, psoriasis, and psoriaticarthritis.

In one embodiment, the TNFα inhibitor used in the invention is ananti-TNFα antibody (also referred to herein as a TNFα antibody), or anantigen-binding fragment thereof, including chimeric, humanized, andhuman antibodies. Examples of TNFα antibodies that may be used in theinvention include, but not limited to, infliximab (Remicade®, Johnsonand Johnson; described in U.S. Pat. No. 5,656,272, incorporated byreference herein), CDP571 (a humanized monoclonal anti-TNF-alpha IgG4antibody), CDP 870 (a humanized monoclonal anti-TNF-alpha antibodyfragment), an anti-TNF dAb (Peptech), CNTO 148 (golimumab; Medarex andCentocor, see WO 02/12502), and adalimumab (HUMIRA® Abbott Laboratories,a human anti-TNF mAb, described in U.S. Pat. No. 6,090,382 as D2E7).Additional TNF antibodies that may be used in the invention aredescribed in U.S. Pat. Nos. 6,593,458; 6,498,237; 6,451,983; and6,448,380, each of which is incorporated by reference herein.

Other examples of TNFα inhibitors which may be used in the methods andcompositions of the invention include etanercept (Enbrel, described inWO 91/03553 and WO 09/406476), soluble TNF receptor Type I, a pegylatedsoluble TNF receptor Type I (PEGs TNF-R1), p55TNFR1gG (Lenercept), andrecombinant TNF binding protein (r-TBP-I) (Serono). Examples of TNFαinhibitors include but are not limited to infliximab (Remicade™), CDP571, CDP 870, anti-TNF dAb, golimumab, adalimumab, etanercept (Enbrel™),p55TNFR1gG (Lenercept) and r-TBP-1. A particularly preferred TNFαinhibitor is adalimumab (HUMIRA®).

In one embodiment, the term “TNFα inhibitor” excludes infliximab. In oneembodiment, the term “TNFα inhibitor” excludes adalimumab. In anotherembodiment, the term “TNFα inhibitor” excludes adalimumab andinfliximab.

In one embodiment, the term “TNFα inhibitor” excludes etanercept, and,optionally, adalimumab, infliximab, and adalimumab and infliximab.

In one embodiment, the term “TNFα antibody” excludes infliximab. In oneembodiment, the term “TNFα antibody” excludes adalimumab. In anotherembodiment, the term “TNFα antibody” excludes adalimumab and infliximab.

In one embodiment, the invention features uses and composition fortreating or determining the efficacy of a TNFα inhibitor for thetreatment of rheumatoid arthritis, wherein the TNFα antibody is anisolated human antibody, or antigen-binding portion thereof, that bindsto human TNFα with high affinity and a low off rate, and also has a highneutralizing capacity. Preferably, the human antibodies used in theinvention are recombinant, neutralizing human anti-hTNFα antibodies. Themost preferred recombinant, neutralizing antibody of the invention isreferred to herein as D2E7, also referred to as HUMIRA® or adalimumab(the amino acid sequence of the D2E7 VL region is shown in SEQ ID NO: 1;the amino acid sequence of the D2E7 VH region is shown in SEQ ID NO: 2).The properties of D2E7 (adalimumab/HUMIRA®) have been described inSalfeld et al., U.S. Pat. Nos. 6,090,382, 6,258,562, and 6,509,015,which are each incorporated by reference herein. The methods of theinvention may also be performed using chimeric and humanized murineanti-hTNFα antibodies which have undergone clinical testing fortreatment of rheumatoid arthritis (see e.g., Elliott, M. J., et al.(1994) Lancet 344:1125-1127; Elliot, M. J., et al. (1994) Lancet344:1105-1110; Rankin, E. C., et al. (1995) Br. J. Rheumatol.34:334-342).

In one embodiment, the method of the invention includes determining theefficacy of adalimumab antibodies and antibody portions,adalimumab-related antibodies and antibody portions, or other humanantibodies and antibody portions with equivalent properties toadalimumab, such as high affinity binding to hTNFα with low dissociationkinetics and high neutralizing capacity, for the treatment of rheumatoidarthritis. In one embodiment, the invention provides treatment with anisolated human antibody, or an antigen-binding portion thereof, thatdissociates from human TNFα with a K_(d) of 1×10⁻⁸ M or less and aK_(off) rate constant of 1×10⁻³ s⁻¹ or less, both determined by surfaceplasmon resonance, and neutralizes human TNFα cytotoxicity in a standardin vitro L929 assay with an IC₅₀ of 1×10⁻⁷ M or less. More preferably,the isolated human antibody, or antigen-binding portion thereof,dissociates from human TNFα with a K_(off) of 5×10⁻⁴ s⁻¹ or less, oreven more preferably, with a K_(off) of 1×10⁻⁴ s⁻¹ or less. Morepreferably, the isolated human antibody, or antigen-binding portionthereof, neutralizes human TNFα cytotoxicity in a standard in vitro L929assay with an IC₅₀ of 1×10⁻⁸ M or less, even more preferably with anIC₅₀ of 1×10⁻⁹ M or less and still more preferably with an IC₅₀ of1×10⁻¹⁰ M or less. In a preferred embodiment, the antibody is anisolated human recombinant antibody, or an antigen-binding portionthereof.

It is well known in the art that antibody heavy and light chain CDR3domains play an important role in the binding specificity/affinity of anantibody for an antigen. Accordingly, in another aspect, the inventionpertains to treating Crohn's disease by administering human antibodiesthat have slow dissociation kinetics for association with hTNFα and thathave light and heavy chain CDR3 domains that structurally are identicalto or related to those of D2E7. Position 9 of the D2E7 VL CDR3 can beoccupied by Ala or Thr without substantially affecting the K_(off).Accordingly, a consensus motif for the D2E7 VL CDR3 comprises the aminoacid sequence: Q-R—Y—N—R-A-P—Y-(T/A) (SEQ ID NO: 3). Additionally,position 12 of the D2E7 VH CDR3 can be occupied by Tyr or Asn, withoutsubstantially affecting the K_(off). Accordingly, a consensus motif forthe D2E7 VH CDR3 comprises the amino acid sequence:V—S—Y-L-S-T-A-S—S-L-D-(Y/N) (SEQ ID NO: 4). Moreover, as demonstrated inExample 2 of U.S. Pat. No. 6,090,382, the CDR3 domain of the D2E7 heavyand light chains is amenable to substitution with a single alanineresidue (at position 1, 4, 5, 7 or 8 within the VL CDR3 or at position2, 3, 4, 5, 6, 8, 9, 10 or 11 within the VH CDR3) without substantiallyaffecting the K_(off). Still further, the skilled artisan willappreciate that, given the amenability of the D2E7 VL and VH CDR3domains to substitutions by alanine, substitution of other amino acidswithin the CDR3 domains may be possible while still retaining the lowoff rate constant of the antibody, in particular substitutions withconservative amino acids. Preferably, no more than one to fiveconservative amino acid substitutions are made within the D2E7 VL and/orVH CDR3 domains. More preferably, no more than one to three conservativeamino acid substitutions are made within the D2E7 VL and/or VH CDR3domains. Additionally, conservative amino acid substitutions should notbe made at amino acid positions critical for binding to hTNFα. Positions2 and 5 of the D2E7 VL CDR3 and positions 1 and 7 of the D2E7 VH CDR3appear to be critical for interaction with hTNFα and thus, conservativeamino acid substitutions preferably are not made at these positions(although an alanine substitution at position 5 of the D2E7 VL CDR3 isacceptable, as described above) (see U.S. Pat. No. 6,090,382).

Accordingly, in another embodiment, the antibody or antigen-bindingportion thereof preferably contains the following characteristics:

a) dissociates from human TNFα with a K_(off) rate constant of 1×10⁻³s⁻¹ or less, as determined by surface plasmon resonance;

b) has a light chain CDR3 domain comprising the amino acid sequence ofSEQ ID NO: 3, or modified from SEQ ID NO: 3 by a single alaninesubstitution at position 1, 4, 5, 7 or 8 or by one to five conservativeamino acid substitutions at positions 1, 3, 4, 6, 7, 8 and/or 9;

c) has a heavy chain CDR3 domain comprising the amino acid sequence ofSEQ ID NO: 4, or modified from SEQ ID NO: 4 by a single alaninesubstitution at position 2, 3, 4, 5, 6, 8, 9, 10 or 11 or by one to fiveconservative amino acid substitutions at positions 2, 3, 4, 5, 6, 8, 9,10, 11 and/or 12.

More preferably, the antibody, or antigen-binding portion thereof,dissociates from human TNFα with a K_(off) of 5×10⁻⁴ s⁻¹ or less. Evenmore preferably, the antibody, or antigen-binding portion thereof,dissociates from human TNFα with a K_(off) of 1×10⁻⁴ s⁻¹ or less.

In yet another embodiment, the antibody or antigen-binding portionthereof preferably contains a light chain variable region (LCVR) havinga CDR3 domain comprising the amino acid sequence of SEQ ID NO: 3, ormodified from SEQ ID NO: 3 by a single alanine substitution at position1, 4, 5, 7 or 8, and with a heavy chain variable region (HCVR) having aCDR3 domain comprising the amino acid sequence of SEQ ID NO: 4, ormodified from SEQ ID NO: 4 by a single alanine substitution at position2, 3, 4, 5, 6, 8, 9, 10 or 11. Preferably, the LCVR further has a CDR2domain comprising the amino acid sequence of SEQ ID NO: 5 (i.e., theD2E7 VL CDR2) and the HCVR further has a CDR2 domain comprising theamino acid sequence of SEQ ID NO: 6 (i.e., the D2E7 VH CDR2). Even morepreferably, the LCVR further has CDR1 domain comprising the amino acidsequence of SEQ ID NO: 7 (i.e., the D2E7 VL CDR1) and the HCVR has aCDR1 domain comprising the amino acid sequence of SEQ ID NO: 8 (i.e.,the D2E7 VH CDR1). The framework regions for VL preferably are from theV_(κ)I human germ line family, more preferably from the A20 human germline Vk gene and most preferably from the D2E7 VL framework sequencesshown in FIGS. 1A and 1B of U.S. Pat. No. 6,090,382. The frameworkregions for VH preferably are from the V_(H)3 human germ line family,more preferably from the DP-31 human germ line VH gene and mostpreferably from the D2E7 VH framework sequences shown in FIGS. 2A and 2Bof U.S. Pat. No. 6,090,382.

Accordingly, in another embodiment, the antibody or antigen-bindingportion thereof preferably contains a light chain variable region (LCVR)comprising the amino acid sequence of SEQ ID NO: 1 (i.e., the D2E7 VL)and a heavy chain variable region (HCVR) comprising the amino acidsequence of SEQ ID NO: 2 (i.e., the D2E7 VH). In certain embodiments,the antibody comprises a heavy chain constant region, such as an IgG1,IgG2, IgG3, IgG4, IgA, IgE, IgM or IgD constant region. Preferably, theheavy chain constant region is an IgG1 heavy chain constant region or anIgG4 heavy chain constant region. Furthermore, the antibody can comprisea light chain constant region, either a kappa light chain constantregion or a lambda light chain constant region. Preferably, the antibodycomprises a kappa light chain constant region. Alternatively, theantibody portion can be, for example, a Fab fragment or a single chainFv fragment.

In still other embodiments, the invention includes uses of an isolatedhuman antibody, or antigen-binding portion thereof, containingD2E7-related VL and VH CDR3 domains. For example, antibodies, orantigen-binding portions thereof, with a light chain variable region(LCVR) having a CDR3 domain comprising an amino acid sequence selectedfrom the group consisting of SEQ ID NO: 3, SEQ ID NO: 11, SEQ ID NO: 12,SEQ ID NO: 13, SEQ ID NO: 14, SEQ ID NO: 15, SEQ ID NO: 16, SEQ ID NO:17, SEQ ID NO: 18, SEQ ID NO: 19, SEQ ID NO: 20, SEQ ID NO: 21, SEQ IDNO: 22, SEQ ID NO: 23, SEQ ID NO: 24, SEQ ID NO: 25 and SEQ ID NO: 26 orwith a heavy chain variable region (HCVR) having a CDR3 domaincomprising an amino acid sequence selected from the group consisting ofSEQ ID NO: 4, SEQ ID NO: 27, SEQ ID NO: 28, SEQ ID NO: 29, SEQ ID NO:30, SEQ ID NO: 31, SEQ ID NO: 32, SEQ ID NO: 33, SEQ ID NO: 34 and SEQID NO: 35.

The TNFα antibody used in the methods and compositions of the inventionmay be modified for improved treatment of rheumatoid arthritis. In someembodiments, the TNFα antibody or antigen binding fragments thereof, ischemically modified to provide a desired effect. For example, pegylationof antibodies and antibody fragments of the invention may be carried outby any of the pegylation reactions known in the art, as described, forexample, in the following references: Focus on Growth Factors 3:4-10(1992); EP 0 154 316; and EP 0 401 384 (each of which is incorporated byreference herein in its entirety). Preferably, the pegylation is carriedout via an acylation reaction or an alkylation reaction with a reactivepolyethylene glycol molecule (or an analogous reactive water-solublepolymer). A preferred water-soluble polymer for pegylation of theantibodies and antibody fragments of the invention is polyethyleneglycol (PEG). As used herein, “polyethylene glycol” is meant toencompass any of the forms of PEG that have been used to derivatizeother proteins, such as mono (C1-C10) alkoxy- or aryloxy-polyethyleneglycol.

Methods for preparing pegylated antibodies and antibody fragments of theinvention will generally comprise the steps of (a) reacting the antibodyor antibody fragment with polyethylene glycol, such as a reactive esteror aldehyde derivative of PEG, under conditions whereby the antibody orantibody fragment becomes attached to one or more PEG groups, and (b)obtaining the reaction products. It will be apparent to one of ordinaryskill in the art to select the optimal reaction conditions or theacylation reactions based on known parameters and the desired result.

Pegylated antibodies and antibody fragments may generally be used totreat rheumatoid arthritis by administration of the TNFα antibodies andantibody fragments described herein. Generally the pegylated antibodiesand antibody fragments have increased half-life, as compared to thenonpegylated antibodies and antibody fragments. The pegylated antibodiesand antibody fragments may be employed alone, together, or incombination with other pharmaceutical compositions.

In yet another embodiment of the invention, TNFα antibodies or fragmentsthereof can be altered wherein the constant region of the antibody ismodified to reduce at least one constant region-mediated biologicaleffector function relative to an unmodified antibody. To modify anantibody of the invention such that it exhibits reduced binding to theFc receptor, the immunoglobulin constant region segment of the antibodycan be mutated at particular regions necessary for Fc receptor (FcR)interactions (see e.g., Canfield, S. M. and S. L. Morrison (1991) J.Exp. Med. 173:1483-1491; and Lund, J. et al. (1991) J. of Immunol.147:2657-2662). Reduction in FcR binding ability of the antibody mayalso reduce other effector functions that rely on FcR interactions, suchas opsonization and phagocytosis and antigen-dependent cellularcytotoxicity.

An antibody or antibody portion used in the compositions and methods ofthe invention can be derivatized or linked to another functionalmolecule (e.g., another peptide or protein). Accordingly, the antibodiesand antibody portions of the invention are intended to includederivatized and otherwise modified forms of the human anti-hTNFαantibodies described herein, including immunoadhesion molecules. Forexample, an antibody or antibody portion of the invention can befunctionally linked (by chemical coupling, genetic fusion, noncovalentassociation or otherwise) to one or more other molecular entities, suchas another antibody (e.g., a bispecific antibody or a diabody), adetectable agent, a cytotoxic agent, a pharmaceutical agent, and/or aprotein or peptide that can mediate associate of the antibody orantibody portion with another molecule (such as a streptavidin coreregion or a polyhistidine tag).

One type of derivatized antibody is produced by crosslinking two or moreantibodies (of the same type or of different types, e.g., to createbispecific antibodies). Suitable crosslinkers include those that areheterobifunctional, having two distinctly reactive groups separated byan appropriate spacer (e.g., m-maleimidobenzoyl-N-hydroxysuccinimideester) or homobifunctional (e.g., disuccinimidyl suberate). Such linkersare available from Pierce Chemical Company, Rockford, Ill.

Useful detectable agents with which an antibody or antibody portion ofthe invention may be derivatized include fluorescent compounds.Exemplary fluorescent detectable agents include fluorescein, fluoresceinisothiocyanate, rhodamine, 5-dimethylamine-1-napthalenesulfonylchloride, phycoerythrin and the like. An antibody may also bederivatized with detectable enzymes, such as alkaline phosphatase,horseradish peroxidase, glucose oxidase and the like. When an antibodyis derivatized with a detectable enzyme, it is detected by addingadditional reagents that the enzyme uses to produce a detectablereaction product. For example, when the detectable agent horseradishperoxidase is present, the addition of hydrogen peroxide anddiaminobenzidine leads to a colored reaction product, which isdetectable. An antibody may also be derivatized with biotin, anddetected through indirect measurement of avidin or streptavidin binding.

An antibody, or antibody portion, used in the methods and compositionsof the invention, can be prepared by recombinant expression ofimmunoglobulin light and heavy chain genes in a host cell. To express anantibody recombinantly, a host cell is transfected with one or morerecombinant expression vectors carrying DNA fragments encoding theimmunoglobulin light and heavy chains of the antibody such that thelight and heavy chains are expressed in the host cell and, preferably,secreted into the medium in which the host cells are cultured, fromwhich medium the antibodies can be recovered. Standard recombinant DNAmethodologies are used to obtain antibody heavy and light chain genes,incorporate these genes into recombinant expression vectors andintroduce the vectors into host cells, such as those described inSambrook, Fritsch and Maniatis (eds), Molecular Cloning; A LaboratoryManual, Second Edition, Cold Spring Harbor, N.Y., (1989), Ausubel, F. M.et al. (eds.) Current Protocols in Molecular Biology, Greene PublishingAssociates, (1989) and in U.S. Pat. No. 4,816,397 by Boss et al.

To express adalimumab (D2E7) or an adalimumab (D2E7)-related antibody,DNA fragments encoding the light and heavy chain variable regions arefirst obtained. These DNAs can be obtained by amplification andmodification of germline light and heavy chain variable sequences usingthe polymerase chain reaction (PCR). Germline DNA sequences for humanheavy and light chain variable region genes are known in the art (seee.g., the “Vbase” human germline sequence database; see also Kabat, E.A., et al. (1991) Sequences of Proteins of Immunological Interest, FifthEdition, U.S. Department of Health and Human Services, NIH PublicationNo. 91-3242; Tomlinson, I. M., et al. (1992) “The Repertoire of HumanGermline V_(H) Sequences Reveals about Fifty Groups of V_(H) Segmentswith Different Hypervariable Loops” J. Mol. Biol. 227:776-798; and Cox,J. P. L. et al. (1994) “A Directory of Human Germ-line V₇₈ SegmentsReveals a Strong Bias in their Usage” Eur. J. Immunol. 24:827-836; thecontents of each of which are expressly incorporated herein byreference). To obtain a DNA fragment encoding the heavy chain variableregion of D2E7, or a D2E7-related antibody, a member of the V_(H)3family of human germline VH genes is amplified by standard PCR. Mostpreferably, the DP-31 VH germline sequence is amplified. To obtain a DNAfragment encoding the light chain variable region of D2E7, or aD2E7-related antibody, a member of the V_(κ)I family of human germlineVL genes is amplified by standard PCR. Most preferably, the A20 VLgermline sequence is amplified. PCR primers suitable for use inamplifying the DP-31 germline VH and A20 germline VL sequences can bedesigned based on the nucleotide sequences disclosed in the referencescited supra, using standard methods.

Once the germline VH and VL fragments are obtained, these sequences canbe mutated to encode the D2E7 or D2E7-related amino acid sequencesdisclosed herein. The amino acid sequences encoded by the germline VHand VL DNA sequences are first compared to the D2E7 or D2E7-related VHand VL amino acid sequences to identify amino acid residues in the D2E7or D2E7-related sequence that differ from germline. Then, theappropriate nucleotides of the germline DNA sequences are mutated suchthat the mutated germline sequence encodes the D2E7 or D2E7-relatedamino acid sequence, using the genetic code to determine whichnucleotide changes should be made. Mutagenesis of the germline sequencesis carried out by standard methods, such as PCR-mediated mutagenesis (inwhich the mutated nucleotides are incorporated into the PCR primers suchthat the PCR product contains the mutations) or site-directedmutagenesis.

Moreover, it should be noted that if the “germline” sequences obtainedby PCR amplification encode amino acid differences in the frameworkregions from the true germline configuration (i.e., differences in theamplified sequence as compared to the true germline sequence, forexample as a result of somatic mutation), it may be desirable to changethese amino acid differences back to the true germline sequences (i.e.,“backmutation” of framework residues to the germline configuration).

Once DNA fragments encoding D2E7 or D2E7-related VH and VL segments areobtained (by amplification and mutagenesis of germline VH and VL genes,as described above), these DNA fragments can be further manipulated bystandard recombinant DNA techniques, for example to convert the variableregion genes to full-length antibody chain genes, to Fab fragment genesor to a scFv gene. In these manipulations, a VL- or VH-encoding DNAfragment is operatively linked to another DNA fragment encoding anotherprotein, such as an antibody constant region or a flexible linker. Theterm “operatively linked”, as used in this context, is intended to meanthat the two DNA fragments are joined such that the amino acid sequencesencoded by the two DNA fragments remain in-frame.

The isolated DNA encoding the VH region can be converted to afull-length heavy chain gene by operatively linking the VH-encoding DNAto another DNA molecule encoding heavy chain constant regions (CH1, CH2and CH3). The sequences of human heavy chain constant region genes areknown in the art (see e.g., Kabat, E. A., et al. (1991) Sequences ofProteins of Immunological Interest, Fifth Edition, U.S. Department ofHealth and Human Services, NIH Publication No. 91-3242) and DNAfragments encompassing these regions can be obtained by standard PCRamplification. The heavy chain constant region can be an IgG1, IgG2,IgG3, IgG4, IgA, IgE, IgM or IgD constant region, but most preferably isan IgG1 or IgG4 constant region. For a Fab fragment heavy chain gene,the VH-encoding DNA can be operatively linked to another DNA moleculeencoding only the heavy chain CH1 constant region.

The isolated DNA encoding the VL region can be converted to afull-length light chain gene (as well as a Fab light chain gene) byoperatively linking the VL-encoding DNA to another DNA molecule encodingthe light chain constant region, CL. The sequences of human light chainconstant region genes are known in the art (see e.g., Kabat, E. A., etal. (1991) Sequences of Proteins of Immunological Interest, FifthEdition, U.S. Department of Health and Human Services, NIH PublicationNo. 91-3242) and DNA fragments encompassing these regions can beobtained by standard PCR amplification. The light chain constant regioncan be a kappa or lambda constant region, but most preferably is a kappaconstant region.

To create a scFv gene, the VH- and VL-encoding DNA fragments areoperatively linked to another fragment encoding a flexible linker, e.g.,encoding the amino acid sequence (Gly₄-Ser)₃, such that the VH and VLsequences can be expressed as a contiguous single-chain protein, withthe VL and VH regions joined by the flexible linker (see e.g., Bird etal. (1988) Science 242:423-426; Huston et al. (1988) Proc. Natl. Acad.Sci. USA 85:5879-5883; McCafferty et al., Nature (1990) 348:552-554).

To express the antibodies, or antibody portions used in the invention,DNAs encoding partial or full-length light and heavy chains, obtained asdescribed above, are inserted into expression vectors such that thegenes are operatively linked to transcriptional and translationalcontrol sequences. In this context, the term “operatively linked” isintended to mean that an antibody gene is ligated into a vector suchthat transcriptional and translational control sequences within thevector serve their intended function of regulating the transcription andtranslation of the antibody gene. The expression vector and expressioncontrol sequences are chosen to be compatible with the expression hostcell used. The antibody light chain gene and the antibody heavy chaingene can be inserted into separate vector or, more typically, both genesare inserted into the same expression vector. The antibody genes areinserted into the expression vector by standard methods (e.g., ligationof complementary restriction sites on the antibody gene fragment andvector, or blunt end ligation if no restriction sites are present).Prior to insertion of the D2E7 or D2E7-related light or heavy chainsequences, the expression vector may already carry antibody constantregion sequences. For example, one approach to converting the D2E7 orD2E7-related VH and VL sequences to full-length antibody genes is toinsert them into expression vectors already encoding heavy chainconstant and light chain constant regions, respectively, such that theVH segment is operatively linked to the CH segment(s) within the vectorand the VL segment is operatively linked to the CL segment within thevector. Additionally or alternatively, the recombinant expression vectorcan encode a signal peptide that facilitates secretion of the antibodychain from a host cell. The antibody chain gene can be cloned into thevector such that the signal peptide is linked in-frame to the aminoterminus of the antibody chain gene. The signal peptide can be animmunoglobulin signal peptide or a heterologous signal peptide (i.e., asignal peptide from a non-immunoglobulin protein).

In addition to the antibody chain genes, the recombinant expressionvectors of the invention carry regulatory sequences that control theexpression of the antibody chain genes in a host cell. The term“regulatory sequence” is intended to include promoters, enhancers andother expression control elements (e.g., polyadenylation signals) thatcontrol the transcription or translation of the antibody chain genes.Such regulatory sequences are described, for example, in Goeddel; GeneExpression Technology: Methods in Enzymology 185, Academic Press, SanDiego, Calif. (1990). It will be appreciated by those skilled in the artthat the design of the expression vector, including the selection ofregulatory sequences may depend on such factors as the choice of thehost cell to be transformed, the level of expression of protein desired,etc. Preferred regulatory sequences for mammalian host cell expressioninclude viral elements that direct high levels of protein expression inmammalian cells, such as promoters and/or enhancers derived fromcytomegalovirus (CMV) (such as the CMV promoter/enhancer), Simian Virus40 (SV40) (such as the SV40 promoter/enhancer), adenovirus, (e.g., theadenovirus major late promoter (AdMLP)) and polyoma. For furtherdescription of viral regulatory elements, and sequences thereof, seee.g., U.S. Pat. No. 5,168,062 by Stinski, U.S. Pat. No. 4,510,245 byBell et al. and U.S. Pat. No. 4,968,615 by Schaffner et al.

In addition to the antibody chain genes and regulatory sequences, therecombinant expression vectors used in the invention may carryadditional sequences, such as sequences that regulate replication of thevector in host cells (e.g., origins of replication) and selectablemarker genes. The selectable marker gene facilitates selection of hostcells into which the vector has been introduced (see e.g., U.S. Pat.Nos. 4,399,216, 4,634,665 and 5,179,017, all by Axel et al.). Forexample, typically the selectable marker gene confers resistance todrugs, such as G418, hygromycin or methotrexate, on a host cell intowhich the vector has been introduced. Preferred selectable marker genesinclude the dihydrofolate reductase (DHFR) gene (for use in dhfr⁻ hostcells with methotrexate selection/amplification) and the neo gene (forG418 selection).

For expression of the light and heavy chains, the expression vector(s)encoding the heavy and light chains is transfected into a host cell bystandard techniques. The various forms of the term “transfection” areintended to encompass a wide variety of techniques commonly used for theintroduction of exogenous DNA into a prokaryotic or eukaryotic hostcell, e.g., electroporation, calcium-phosphate precipitation,DEAE-dextran transfection and the like. Although it is theoreticallypossible to express the antibodies of the invention in eitherprokaryotic or eukaryotic host cells, expression of antibodies ineukaryotic cells, and most preferably mammalian host cells, is the mostpreferred because such eukaryotic cells, and in particular mammaliancells, are more likely than prokaryotic cells to assemble and secrete aproperly folded and immunologically active antibody. Prokaryoticexpression of antibody genes has been reported to be ineffective forproduction of high yields of active antibody (Boss, M. A. and Wood, C.R. (1985) Immunology Today 6:12-13).

Preferred mammalian host cells for expressing the recombinant antibodiesof the invention include Chinese Hamster Ovary (CHO cells) (includingdhfr-CHO cells, described in Urlaub and Chasin, (1980) Proc. Natl. Acad.Sci. USA 77:4216-4220, used with a DHFR selectable marker, e.g., asdescribed in R. J. Kaufman and P. A. Sharp (1982) Mol. Biol.159:601-621), NSO myeloma cells, COS cells and SP2 cells. Whenrecombinant expression vectors encoding antibody genes are introducedinto mammalian host cells, the antibodies are produced by culturing thehost cells for a period of time sufficient to allow for expression ofthe antibody in the host cells or, more preferably, secretion of theantibody into the culture medium in which the host cells are grown.Antibodies can be recovered from the culture medium using standardprotein purification methods.

Host cells can also be used to produce portions of intact antibodies,such as Fab fragments or scFv molecules. It is understood thatvariations on the above procedure are within the scope of the presentinvention. For example, it may be desirable to transfect a host cellwith DNA encoding either the light chain or the heavy chain (but notboth) of an antibody of this invention. Recombinant DNA technology mayalso be used to remove some or all of the DNA encoding either or both ofthe light and heavy chains that is not necessary for binding to hTNFα.The molecules expressed from such truncated DNA molecules are alsoencompassed by the antibodies of the invention. In addition,bifunctional antibodies may be produced in which one heavy and one lightchain are an antibody of the invention and the other heavy and lightchain are specific for an antigen other than hTNFα by crosslinking anantibody of the invention to a second antibody by standard chemicalcrosslinking methods.

In a preferred system for recombinant expression of an antibody, orantigen-binding portion thereof, of the invention, a recombinantexpression vector encoding both the antibody heavy chain and theantibody light chain is introduced into dhfr-CHO cells by calciumphosphate-mediated transfection. Within the recombinant expressionvector, the antibody heavy and light chain genes are each operativelylinked to CMV enhancer/AdMLP promoter regulatory elements to drive highlevels of transcription of the genes. The recombinant expression vectoralso carries a DHFR gene, which allows for selection of CHO cells thathave been transfected with the vector using methotrexateselection/amplification. The selected transformant host cells areculture to allow for expression of the antibody heavy and light chainsand intact antibody is recovered from the culture medium. Standardmolecular biology techniques are used to prepare the recombinantexpression vector, transfect the host cells, select for transformants,culture the host cells and recover the antibody from the culture medium.

In view of the foregoing, nucleic acid, vector and host cellcompositions that can be used for recombinant expression of theantibodies and antibody portions used in the invention include nucleicacids, and vectors comprising said nucleic acids, comprising the humanTNFα antibody adalimumab (D2E7). The nucleotide sequence encoding theD2E7 light chain variable region is shown in SEQ ID NO: 36. The CDR1domain of the LCVR encompasses nucleotides 70-102, the CDR2 domainencompasses nucleotides 148-168 and the CDR3 domain encompassesnucleotides 265-291. The nucleotide sequence encoding the D2E7 heavychain variable region is shown in SEQ ID NO: 37. The CDR1 domain of theHCVR encompasses nucleotides 91-105, the CDR2 domain encompassesnucleotides 148-198 and the CDR3 domain encompasses nucleotides 295-330.It will be appreciated by the skilled artisan that nucleotide sequencesencoding D2E7-related antibodies, or portions thereof (e.g., a CDRdomain, such as a CDR3 domain), can be derived from the nucleotidesequences encoding the D2E7 LCVR and HCVR using the genetic code andstandard molecular biology techniques.

Recombinant human antibodies of the invention in addition to D2E7 or anantigen binding portion thereof, or D2E7-related antibodies disclosedherein can be isolated by screening of a recombinant combinatorialantibody library, preferably a scFv phage display library, preparedusing human VL and VH cDNAs prepared from mRNA derived from humanlymphocytes. Methodologies for preparing and screening such librariesare known in the art. In addition to commercially available kits forgenerating phage display libraries (e.g., the Pharmacia RecombinantPhage Antibody System, catalog no. 27-9400-01; and the StratageneSurfZAP™ phage display kit, catalog no. 240612), examples of methods andreagents particularly amenable for use in generating and screeningantibody display libraries can be found in, for example, Ladner et al.U.S. Pat. No. 5,223,409; Kang et al. PCT Publication No. WO 92/18619;Dower et al. PCT Publication No. WO 91/17271; Winter et al. PCTPublication No. WO 92/20791; Markland et al. PCT Publication No. WO92/15679; Breitling et al. PCT Publication No. WO 93/01288; McCaffertyet al. PCT Publication No. WO 92/01047; Garrard et al. PCT PublicationNo. WO 92/09690; Fuchs et al. (1991) Bio/Technology 9:1370-1372; Hay etal. (1992) Hum Antibod Hybridomas 3:81-65; Huse et al. (1989) Science246:1275-1281; McCafferty et al., Nature (1990) 348:552-554; Griffithset al. (1993) EMBO J 12:725-734; Hawkins et al. (1992) J Mol Biol226:889-896; Clackson et al. (1991) Nature 352:624-628; Gram et al.(1992) PNAS 89:3576-3580; Garrard et al. (1991) Bio/Technology9:1373-1377; Hoogenboom et al. (1991) Nuc Acid Res 19:4133-4137; andBarbas et al. (1991) PNAS 88:7978-7982.

In a preferred embodiment, to isolate human antibodies with highaffinity and a low off rate constant for hTNFα, a murine anti-hTNFαantibody having high affinity and a low off rate constant for hTNFα(e.g., MAK 195, the hybridoma for which has deposit number ECACC 87050801) is first used to select human heavy and light chain sequenceshaving similar binding activity toward hTNFα, using the epitopeimprinting methods described in Hoogenboom et al., PCT Publication No.WO 93/06213. The antibody libraries used in this method are preferablyscFv libraries prepared and screened as described in McCafferty et al.,PCT Publication No. WO 92/01047, McCafferty et al., Nature (1990)348:552-554; and Griffiths et al., (1993) EMBO J 12:725-734. The scFvantibody libraries preferably are screened using recombinant human TNFαas the antigen.

Once initial human VL and VH segments are selected, “mix and match”experiments, in which different pairs of the initially selected VL andVH segments are screened for hTNFα binding, are performed to selectpreferred VL/VH pair combinations. Additionally, to further improve theaffinity and/or lower the off rate constant for hTNFα binding, the VLand VH segments of the preferred VL/VH pair(s) can be randomly mutated,preferably within the CDR3 region of VH and/or VL, in a processanalogous to the in vivo somatic mutation process responsible foraffinity maturation of antibodies during a natural immune response. Thisin vitro affinity maturation can be accomplished by amplifying VH and VLregions using PCR primers complimentary to the VH CDR3 or VL CDR3,respectively, which primers have been “spiked” with a random mixture ofthe four nucleotide bases at certain positions such that the resultantPCR products encode VH and VL segments into which random mutations havebeen introduced into the VH and/or VL CDR3 regions. These randomlymutated VH and VL segments can be rescreened for binding to hTNFα andsequences that exhibit high affinity and a low off rate for hTNFαbinding can be selected.

Following screening and isolation of an hTNFα antibody of the inventionfrom a recombinant immunoglobulin display library, nucleic acid encodingthe selected antibody can be recovered from the display package (e.g.,from the phage genome) and subcloned into other expression vectors bystandard recombinant DNA techniques. If desired, the nucleic acid can befurther manipulated to create other antibody forms of the invention(e.g., linked to nucleic acid encoding additional immunoglobulindomains, such as additional constant regions). To express a recombinanthuman antibody isolated by screening of a combinatorial library, the DNAencoding the antibody is cloned into a recombinant expression vector andintroduced into a mammalian host cells, as described in further detailin above.

Methods of isolating human neutralizing antibodies with high affinityand a low off rate constant for hTNFα are described in U.S. Pat. Nos.6,090,382, 6,258,562, and 6,509,015, each of which is incorporated byreference herein.

IV. Substances for Use in the Automatic Injection Device

The methods and compositions of the invention can be used with automaticinjection devices that administer essentially any substance ormedication that is suitable for administration by injection. Typically,the substance or medication will be in a fluid, e.g., liquid form,although medications in other forms such as gels or semi-solids,slurries, particulate solutions, etc. also may suitable for use if theautomatic injection device is designed to permit the administration ofsuch forms of the medication.

Preferred medications are biological agents, such as antibodies,cytokines, vaccines, fusion proteins and growth factors. Methods ofmaking antibodies are described above.

Non-limiting examples of other biological agents that can be used as themedication in the automatic injection device include but are not limitedto antibodies to or antagonists of human cytokines or growth factors,for example, TNF, LT, IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8,IL-15, IL-16, IL-18, IL-21, IL-23, interferons, EMAP-II, GM-CSF, FGF,and PDGF; antibodies to cell surface molecules such as CD2, CD3, CD4,CD8, CD25, CD28, CD30, CD40, CD45, CD69, CD80 (B7.1), CD86 (B7.2), CD90,CTLA or their ligands including CD154 (gp39 or CD40L); TNFα convertingenzyme (TACE) inhibitors; IL-1 inhibitors (Interleukin-1-convertingenzyme inhibitors, IL-1RA etc.); Interleukin 11; IL-18 antagonistsincluding IL-18 antibodies or soluble IL-18 receptors, or IL-18 bindingproteins; non-depleting anti-CD4 inhibitors; antagonists of theco-stimulatory pathway CD80 (B7.1) or CD86 (B7.2) including antibodies,soluble receptors or antagonistic ligands; agents which interfere withsignalling by proinflammatory cytokines such as TNFα or IL-1 (e.g. IRAK,NIK, IKK, p38 or MAP kinase inhibitors); IL-1β converting enzyme (ICE)inhibitors; T-cell signalling inhibitors such as kinase inhibitors;metalloproteinase inhibitors; angiotensin converting enzyme inhibitors;soluble cytokine receptors and derivatives thereof (e.g. soluble p55 orp75 TNF receptors and the derivatives p75TNFRIgG (Enbrel™ and p55TNFRIgG(Lenercept)), sIL-1RI, sIL-1RII, sIL-6R); antiinflammatory cytokines(e.g. IL-4, IL-10, IL-11, IL-13 and TGF-beta); Rituximab; IL-1 TRAP;MRA; CTLA4-Ig; IL-18 BP; anti-IL-18; anti-IL15; IDEC-CE9.1/SB 210396(non-depleting primatized anti-CD4 antibody; IDEC/SmithKline; see e.g.,Arthritis & Rheumatism (1995) Vol. 38, S185); DAB 486-IL-2 and/or DAB389-IL-2 (IL-2 fusion proteins; Seragen; see e.g., Arthritis &Rheumatism (1993) Vol. 36, 1223); Anti-Tac (humanized anti-IL-2Ra;Protein Design Labs/Roche); IL-4 (anti-inflammatory cytokine;DNAX/Schering); IL-10 (SCH 52000; recombinant IL-10, anti-inflammatorycytokine; DNAX/Schering); IL-10 and/or IL-4 agonists (e.g., agonistantibodies); IL-1RA (IL-1 receptor antagonist; Synergen/Amgen); anakinra(Kineret®/Amgen); TNF-bp/s-TNF (soluble TNF binding protein; see e.g.,Arthritis & Rheumatism (1996) Vol. 39, No. 9 (supplement), 5284; Amer.J. Physiol.—Heart and Circulatory Physiology (1995) Vol. 268, pp.37-42); R973401 (phosphodiesterase Type IV inhibitor; see e.g.,Arthritis & Rheumatism (1996) Vol. 39, No. 9 (supplement), S282); MK-966(COX-2 Inhibitor; see e.g., Arthritis & Rheumatism (1996) Vol. 39, No. 9(supplement), S81); Iloprost (see e.g., Arthritis & Rheumatism (1996)Vol. 39, No. 9 (supplement), S82); zap-70 and/or lck inhibitor(inhibitor of the tyrosine kinase zap-70 or lck); VEGF inhibitor and/orVEGF-R inhibitor (inhibitors of vascular endothelial cell growth factoror vascular endothelial cell growth factor receptor; inhibitors ofangiogenesis); TNF-convertase inhibitors; anti-IL-12 antibodies;anti-IL-18 antibodies; interleukin-11 (see e.g., Arthritis & Rheumatism(1996) Vol. 39, No. 9 (supplement), S296); interleukin-13 (see e.g.,Arthritis & Rheumatism (1996) Vol. 39, No. 9 (supplement), S308);interleukin -17 inhibitors (see e.g., Arthritis & Rheumatism (1996) Vol.39, No. 9 (supplement), S120); anti-thymocyte globulin; anti-CD4antibodies; CD5-toxins; ICAM-1 antisense phosphorothioateoligo-deoxynucleotides (ISIS 2302; Isis Pharmaceuticals, Inc.); solublecomplement receptor 1 (TP10; T Cell Sciences, Inc.); and anti-IL2Rantibodies.

Pharmaceutical compositions may be loaded into the automatic injectiondevice of the invention for delivery to a user. In one embodiment,antibodies, antibody-portions, as well as other TNFα inhibitors, can beincorporated into pharmaceutical compositions suitable foradministration to a user using the device of the invention. Typically,the pharmaceutical composition comprises an antibody, antibody portion,or other TNFα inhibitor, and a pharmaceutically acceptable carrier. Asused herein, “pharmaceutically acceptable carrier” includes any and allsolvents, dispersion media, coatings, antibacterial and antifungalagents, isotonic and absorption delaying agents, and the like that arephysiologically compatible. Examples of pharmaceutically acceptablecarriers include one or more of water, saline, phosphate bufferedsaline, dextrose, glycerol, ethanol and the like, as well ascombinations thereof. In many cases, it is preferable to includeisotonic agents, for example, sugars, polyalcohols such as mannitol,sorbitol, or sodium chloride in the composition. Pharmaceuticallyacceptable carriers may further comprise minor amounts of auxiliarysubstances such as wetting or emulsifying agents, preservatives orbuffers, which enhance the shelf life or effectiveness of the antibody,antibody portion, or other TNFα inhibitor.

The compositions for use in the methods and compositions of theinvention may be in a variety of forms in accordance with administrationvia the device of the invention, including, for example, liquidsolutions (e.g., injectable and infusible solutions), dispersions orsuspensions. In a preferred embodiment, the antibody or other TNFαinhibitor is administered by subcutaneous injection using the device ofthe invention. In one embodiment, the user administers the TNFαinhibitor, including, but not limited to, TNFα antibody, orantigen-binding portion thereof, to himself/herself using the device ofthe invention

Therapeutic compositions typically must be sterile and stable under theconditions of manufacture and storage. The composition can be formulatedas a solution, microemulsion, dispersion, liposome, or other orderedstructure suitable to high drug concentration. Sterile injectablesolutions can be prepared by incorporating the active compound (i.e.,antibody, antibody portion, or other TNFα inhibitor) in the requiredamount in an appropriate solvent with one or a combination ofingredients enumerated above, as required, followed by filteredsterilization. Generally, dispersions are prepared by incorporating theactive compound into a sterile vehicle that contains a basic dispersionmedium and the required other ingredients from those enumerated above.In the case of sterile powders for the preparation of sterile injectablesolutions, the preferred methods of preparation are vacuum drying andfreeze-drying that yields a powder of the active ingredient plus anyadditional desired ingredient from a previously sterile-filteredsolution thereof. The proper fluidity of a solution can be maintained,for example, by the use of a coating such as lecithin, by themaintenance of the required particle size in the case of dispersion andby the use of surfactants. Prolonged absorption of injectablecompositions can be brought about by including in the composition anagent that delays absorption, for example, monostearate salts andgelatin.

In one embodiment, the invention includes an automatic injection device,e.g., autoinjector pen, comprising an effective TNFα inhibitor and apharmaceutically acceptable carrier. Thus, the invention provides aprefilled automatic injection device comprising a TNFα inhibitor.

In one embodiment, the antibody or antibody portion for use in themethods of the invention is incorporated into a pharmaceuticalformulation as described in PCT/IB03/04502 and U.S. Appln. No.20040033228, incorporated by reference herein. This formulation includesa concentration 50 mg/ml of the antibody D2E7 (adalimumab), wherein oneautoinjector pen comprises 40 mg of antibody for subcutaneous injection.In one embodiment, the automatic injection device of the invention (ormore specifically the syringe of the device) comprises a formulation ofadalimumab having the following formula: adalimumab, sodium chloride,monobasic sodium phosphate dihydrate, dibasic sodium phosphatedihydrate, sodium citrate, citric acid monohydrate, mannitol,polysorbate 80 and water, e.g., water for injection. In anotherembodiment, the automatic injection device comprises a volume ofadalimumab including 40 mg adalimumab, 4.93 mg sodium chloride, 0.69 mgmonobasic sodium phosphate dihydrate, 1.22 mg dibasic sodium phosphatedihydrate, 0.24 mg sodium citrate, 1.04 mg citric acid monohydrate, 9.6mg mannitol, 0.8 mg polysorbate 80 and water, e.g., water for injection.In one embodiment, sodium hydroxide is added as necessary to adjust pH.

The dose amount of TNFα inhibitor in the automatic injection device mayvary according to the disorder for which the TNFα inhibitor is beingused to treat. In one embodiment, the invention includes an automaticinjection device comprising a dose of adalimumab of about 20 mg ofadalimumab; 40 mg of adalimumab; 80 mg of adalimumab; and 160 mg ofadalimumab. It should be noted that for all ranges described herein,including the dose ranges, all numbers intermediary to the recitedvalues are included in the invention, e.g., 36 mg of adalimumab, 48 mgof adalimumab, etc. In addition ranges recited using said numbers arealso included, e.g., 40 to 80 mg of adalimumab. The numbers recitedherein are not intended to limit the scope of the invention.

The TNFα antibodies and inhibitors used in the invention may also beadministered in the form of protein crystal formulations that include acombination of protein crystals encapsulated within a polymeric carrierto form coated particles. The coated particles of the protein crystalformulation may have a spherical morphology and be microspheres of up to500 micro meters in diameter or they may have some other morphology andbe microparticulates. The enhanced concentration of protein crystalsallows the antibody of the invention to be delivered subcutaneously. Inone embodiment, the TNFα antibodies of the invention are delivered via aprotein delivery system, wherein one or more of a protein crystalformulation or composition, is administered to a user with aTNFα-related disorder. Compositions and methods of preparing stabilizedformulations of whole antibody crystals or antibody fragment crystalsare also described in WO 02/072636, which is incorporated by referenceherein. In one embodiment, a formulation comprising the crystallizedantibody fragments described in PCT/IB03/04502 and U.S. Appln. No.20040033228, incorporated by reference herein, is used to treatrheumatoid arthritis using the methods of the invention.

Supplementary active compounds can also be incorporated into thecompositions. In certain embodiments, an antibody or antibody portionfor use in the methods of the invention is coformulated with and/orcoadministered with one or more additional therapeutic agents, includinga rheumatoid arthritis inhibitor or antagonist. For example, ananti-hTNFα antibody or antibody portion may be coformulated and/orcoadministered with one or more additional antibodies that bind othertargets associated with TNFα related disorders (e.g., antibodies thatbind other cytokines or that bind cell surface molecules), one or morecytokines, soluble TNFα receptor (see e.g., PCT Publication No. WO94/06476) and/or one or more chemical agents that inhibit hTNFαproduction or activity (such as cyclohexane-ylidene derivatives asdescribed in PCT Publication No. WO 93/19751) or any combinationthereof. Furthermore, one or more antibodies of the invention may beused in combination with two or more of the foregoing therapeuticagents. Such combination therapies may advantageously utilize lowerdosages of the administered therapeutic agents, thus avoiding possibleside effects, complications or low level of response by the patientassociated with the various monotherapies. Additional agents that may beused in combination with a TNFα antibody or antibody portion aredescribed in U.S. application Ser. No. 11/800,531, which is incorporatedin its entirety herein.

The automatic injection device, e.g., autoinjector pen, of the inventionmay include a “therapeutically effective amount” or a “prophylacticallyeffective amount” of an antibody or antibody portion of the invention. A“therapeutically effective amount” refers to an amount effective, atdosages and for periods of time necessary, to achieve the desiredtherapeutic result. A therapeutically effective amount of the antibody,antibody portion, or other TNFα inhibitor may vary according to factorssuch as the disease state, age, sex, and weight of the individual, andthe ability of the antibody, antibody portion, other TNFα inhibitor toelicit a desired response in the individual. A therapeutically effectiveamount is also one in which any toxic or detrimental effects of theantibody, antibody portion, or other TNFα inhibitor are outweighed bythe therapeutically beneficial effects. A “prophylactically effectiveamount” refers to an amount effective, at dosages and for periods oftime necessary, to achieve the desired prophylactic result. Typically,since a prophylactic dose is used in patients prior to or at an earlierstage of disease, the prophylactically effective amount will be lessthan the therapeutically effective amount.

V. Articles of Manufacture of the Invention

The invention also provides an article of manufacture or kit comprisingthe automatic injection device of the invention. In one embodiment ofthe invention, the kit comprises an automatic injector device, e.g., anautoinjector pen such as the HUMIRA® pen, comprising a liquid drug,e.g., a TNFα inhibitor, such as an antibody, and instructions foradministration of the liquid drug. In one embodiment, the kit comprisesinstructions for delivering a TNFα inhibitor for treatment of a disorderin which TNFα is detrimental, e.g., rheumatoid arthritis, using theautomatic injection device. The instructions may describe how, e.g.,subcutaneously, and when, e.g., at week 0, week 2, week 4, etc., thedose of TNFα inhibitor shall be administered to a patient for treatment.

An article of manufacture, also referred to herein as a kit, refers to apackaged product comprising the automatic injection device of theinvention. The kit preferably comprises a box or container that holdsthe components of the kit, i.e., automatic injection device. In oneembodiment, the automatic injection device, e.g., an autoinjector pen,is housed in a dose tray within the kit or article. The kit may alsoinclude instructions for administering a substance, such as a liquiddrug, e.g., a TNFα antibody, to a patient using the automatic injectiondevice of the invention. The term “package insert” is used to refer toinstructions customarily included in commercial packages of therapeuticproducts, including liquid drugs, that contain information about theindications, usage, dosage, administration, contraindications and/orwarnings concerning the use of such therapeutic products. In oneembodiment, the package insert is the label for the therapeuticsubstance provided by the kit.

The kit or article of manufacture may include a label or a Food and DrugAdministration approved label, which provides a protocol for using theautomatic injection device for administering the substance, e.g., TNFαinhibitor. Thus, the invention also includes labels used alone or incombination with articles of manufacture which provide information to apatient regarding the automatic injection device, including informationsuch as how to use the device, what substance, e.g., liquid dose, thedevice holds for administration to a patient, and how to dispose of thedevice once administration is complete. In one embodiment, the label isfound on a package insert. In one embodiment, the label is a packageinsert that includes a Patient Information Leaflet which providesinformation to a patient regarding how to use the automatic injectiondevice of the invention.

The kit or article of manufacture of the invention may containinformation regarding the automatic injection device with respect to howthe device is packaged within the kit or article. The kit may comprise adose tray comprising the automatic injection device of the inventioncontaining a substance, e.g., a TNFα inhibitor. In one embodiment, thedose tray is for single use of the device for delivering the agent. Inanother example, the kit may include 2 or more dose trays, eachcontaining an automatic injection device, e.g., autoinjector pen. Thekit or article of manufacture may also indicate related items needed forusing the automatic injection device, e.g., alcohol preps, packageinsert with an attached patient information leaflet, and/or a patientinformation booklet. Such written material, e.g.,_package inserts withan attached patient information leaflet, and/or a patient informationbooklet, may be used to provide the recipient with information regardingadministration techniques, common adverse events, disposal information,etc. In one embodiment, the kit or article of manufacture of theinvention indicates in a manner visible from the outside of thepackaging of the kit or article, that the kit or article contains 2 dosetrays, 2 alcohol preps, one_package insert with an attached patientinformation leaflet, and one patient information booklet.

The kit or article of manufacture of the invention may containinformation, for example on a label, regarding how a liquid dose of adrug, e.g., a TNFα inhibitor, such as a TNFα antibody (adalimumab), ispackaged within the automatic injection device, e.g, autoinjector pen,of the invention. For example, in one embodiment, the label of theinvention may indicate that adalimumab is dispensed in a cartoncontaining 6 alcohol preps and 6 dose trays (Crohn's Disease StarterPackage). In one embodiment, the label also may indicate each dose trayconsists of a single-use pen each pen, containing a 1 mL prefilled glasssyringe with a fixed 27 gauge ½ inch needle, providing 40 mg (0.8 mL) ofHUMIRA®.

In one embodiment the kit or article of manufacture of the inventionincludes information indicating that the automatic injection deviceprovided within the kit comprises a formulation comprising the humanantibody adalimumab (adalimumab/HUMIRA®/D2E7), as described inPCT/IB03/04502 and U.S. application Ser. No. 10/222,140, incorporated byreference herein.

In one embodiment, the kit or article of manufacture of the inventionmay contain information, for example on a label, which describes thatHUMIRA® is supplied as a sterile, preservative-free solution ofadalimumab for subcutaneous administration. The label may furtherdescribe that the drug product is supplied as either a single-use, 1 mLprefilled glass syringe or as a single-use, prefilled pen (HUMIRA® Pen).The label of the invention may indicate that enclosed within the pen isa single-use, 1 mL prefilled glass syringe. The label of the inventionmay further indicate that the solution of HUMIRA® is clear andcolorless, with a pH of about 5.2. The label may also indicate thatHUMIRA® (adalimumab) is supplied in pre-filled syringes or in prefilledpens as a preservative-free, sterile solution for subcutaneousadministration. In one embodiment, the label indicates that theautomatic injection device of the invention containing adalimumab isprovided in a HUMIRA® pen carton, wherein HUMIRA® is dispensed in acarton containing two alcohol preps and two dose trays. The label mayfurther specify that each dose tray consists of at least one single-usepen, containing a 1 mL prefilled glass syringe with a fixed 27 gauge ½inch needle, providing 40 mg (0.8 mL) of HUMIRA®.

The kit or article of manufacture of the invention may containinformation, for example on a label, which provides informationregarding how the automatic invention device should appear in the kitand/or how the substance contained within the automatic injectiondevice, e.g., liquid drug, should appear. Such information may beprovided to insure safety regarding the administration of the substanceto a patient, such that a patient would know whether the kit and/orautomatic injection device had been tampered with and/or whether thesubstance had been compromised such that administration should not beperformed. In one embodiment, the label indicates that the solution inthe HUMIRA® Pen should be carefully inspected visually for particulatematter and discoloration prior to subcutaneous administration.

The kit or article of manufacture of the invention may containinformation, for example on a label, which provides instructionsregarding how to use the automatic injection device of the invention,including administration of the substance, e.g., liquid drug, heldwithin the device. In one embodiment, the label indicates that patientsusing the HUMIRA® Pen should be instructed to inject the full amount inthe syringe (0.8 mL), which provides 40 mg of HUMIRA®, according to thedirections provided in the Patient Information Leaflet.

The kit or article of manufacture of the invention may containinformation, for example on a label, which provides instruction forpreparing to use the pen of the invention. For example, the label mayprovide instructions for setting up for an injection with the pen. Inone embodiment, the invention provides a pen filled with HUMIRA®,wherein a label for said pen may indicate that a patient will need thefollowing items for each dose: one HUMIRA® Pen and 1 alcohol prep(swab). The label may also indicate that the patient should find a cleanflat working surface. The label may also indicate that the pen shouldnot be used if seals on top and bottom of carton are broken or missing,as well as, optionally, an indication that the patient should contacttheir pharmacist if the seals are broken. The label may indicate to apatient that he should remove one dose tray containing, for example, apen of HUMIRA®, from the refrigerator (if the substance, e.g., liquiddrug, requires refrigeration). Additionally, a label indicating use ofpen filled with HUMIRA® may indicate that a patient should not use a Penthat is frozen or if it has been left in direct sunlight. The label mayalso indicate that if the patient does not have all of the pieces neededto give an injection, a pharmacist should be called. The label may alsoindicate that the patient should use only the items provided in the boxthe substance, e.g., HUMIRA®, comes in.

For labels of the invention relating to an autoinjector pen comprisingadalimumab, the label may indicate that the patient should check andmake sure the name HUMIRA® appears on the dose tray and pen label; thatthe patient should check the expiration date on the dose tray label andthe pen label to make sure the date has not passed, and, further thatthe patient should not use a pen if the date has passed; and that thepatient should have a puncture proof container nearby for disposing ofthe used pen.

The kit or article of manufacture may also contain material for use,either within the package or through accompanying information, fortreatment of the disorders described herein. In one embodiment, thepackaging is specific to a disorder that is being treated with a TNFαantibody, e.g., adalimumab. The kit or article of manufacture furthercan include a second agent (as described herein) packaged with orco-introduced with instructions for using the second agent with a firstagent (as described herein).

Methods for using the automatic injection device of the invention aredescribed in more detail below and in the Examples. Moreover, any of themethods described herein relating to the automatic injection device maybe included in a label of the invention.

VI. Methods and Compositions for Use of an Automatic Injection DeviceMethods and Compositions for Delivery of a Substance Using an AutomaticInjection Device

The invention also provides methods of using the automatic injectiondevice of the invention for delivering a substance, e.g., medication orliquid dose of a drug such as a TNFα inhibitor. In one embodiment, theautomatic injection device is an autoinjector pen, such as a HUMIRA®pen.

Included in the methods are methods for preparing to use the automaticinjection device, e.g., autoinjector pen, of the invention.

Use of the automatic injection device may require that a patient firstchoose and prepare an injection site. For example, methods for choosingand preparing an injection site for administration with an autoinjectorpen, such as the HUMIRA® pen, include first washing the hands of thepatient thoroughly. Generally, a clean and healthy part of the patient'sbody is selected to receive the injection from the automatic injectiondevice. In one embodiment, a site is chosen on the front of thepatient's thighs or abdomen. If the abdomen is chosen, the patientshould avoid the area 2 inches around the navel. For injection with anautoinjector pen, such as a HUMIRA® pen, a different site should bechosen each time an injection is given. Each new injection should begiven at least one inch from a site used previously. Areas where theskin is tender, bruised, red or hard or where there are scars or stretchmarks should generally not be used as injection sites. A patient mayfind it helpful to keep notes on the location of previous injections.

Once an injection site is selected, the patient generally cleans thearea. In one embodiment, the site where HUMIRA® is to be injected isfirst wiped with an alcohol prep (swab), using a circular motion. Oncecleaned, the injection site area should not be touched again until thepatient is ready to inject.

The methods of the invention also include preparing the dose of thesubstance within the automatic injection device, e.g., autoinjector pen,to be injected. In one embodiment, the autoinjector pen is held with thefirst removable cap pointing up. The patient should examine the solutionor substance, e.g., liquid drug, through the windows on the side of theautomatic injection device, e.g., autoinjector pen, to make sure, forexample, the liquid is clear and colorless. Generally, the automaticinjection device, e.g., autoinjector pen, should not be used if theliquid is cloudy or discolored or has flakes or particles in it. Inaddition, an automatic injection device, e.g., autoinjector pen,comprising adalimumab should be not used if it is frozen.

Once it has been determined that the automatic injection device, e.g.,autoinjector pen, is satisfactory for use in and injection, the devicemay be held with the first removable cap pointed down. Such an actionmay serve to determine the level of the liquid drug within the automaticinjection device, e.g., autoinjector pen.

In one embodiment, prior to injection, one should check to make surethat the amount of liquid in the automatic injection device, e.g.,autoinjector pen, is the same or close to the line visible through thewindow. In one embodiment, the line represents a full dose of theproduct. The top of the liquid may be curved. If the automatic injectiondevice, e.g., autoinjector pen, does not have the correct amount ofliquid, the autoinjector pen should not be used and, optionally, apharmacist should be called.

Injection methods for delivering a substance, such as a liquid drug,using the automatic injection device, e.g., autoinjector pen, of theinvention may include the following. The automatic injection device,e.g., autoinjector pen, is held with one hand. With the patient's otherhand, the first removable cap is removed and discarded. In oneembodiment, the first removable cap should be pulled straight off and/orshould not be twisted. Following removal of the first removable cap, thepatient should check that the needle sheath of the syringe has come offwith the first removable cap. After removal, the interior needle coveris held in the cap. The needle housed in the syringe barrel should notbe touched. The distal end of the stepped shroud will be exposedfollowing removal of the first removable cap. The first removable capshould not be recapped as the needle may be damaged. In addition, thepatient should take care to avoid dropping or crushing the automaticinjection device, e.g., autoinjector pen, as it contains a syringe.

Following removal of the first removable cap, the second removable cap(also referred to as a safety cap) is removed to expose the activationbutton at the top. The patient should pull the second removable capstraight off. The second removable cap should not be twisted off.Following removal of the first and second removable caps, the automaticinjection device, e.g., an autoinjector pen, is now ready to use. Thepatient should be aware that the automatic injection device, e.g., anautoinjector pen, is activated after removing the second removable cap,and, furthermore, that pressing the activation button under the secondremovable cap will result in discharge of medication. The patient shouldalso be aware that the activation button should not be removed untilproperly positioned. In addition, at this point the automatic injectiondevice, e.g., an autoinjector pen, should not be recapped, as this maycause the unit to discharge.

Once the patient is ready to deliver the injection, the automaticinjection device, e.g., an autoinjector pen, should be positioned sothat the window is in view. With the patient's free hand, a sizable areaof the cleaned skin may be gently squeezed at the injection site,creating a platform on which to position the automatic injection device,e.g., an autoinjector pen. The proximal end of the automatic injectiondevice, e.g., an autoinjector pen, may be positioned the at a 90 degreeangle flush against the platform of skin. The automatic injectiondevice, e.g., so that it will not inject the needle into the patient'sfingers. To begin injection, the activation button is pressed. In oneembodiment, the activation button is pressed using a finger, e.g., theindex finger of the patient, to begin the injection. Alternatively, inanother embodiment, the patient may also use a thumb to press theactivation button to begin the injection. During the injection, thepatient should try not to cover the window. In one embodiment, when theactivation button is pressed, there will be an audible indicator, e.g,click. The audible indicator, e.g., click, may indicate the start of theinjection. In one embodiment, an autoinjector pen comprising adalimumabmakes noise once the activation button is pressed. Once the activationbutton is pressed, pressure should be kept on the activation button andthe patient may continue to hold the automatic injection device, e.g.,autoinjector pen, with steady pressure on the injection site until theprocess is finished. In one embodiment, the process of pressing theactivation button to complete the injection may take up to about 10seconds. For injection, constant pressure is maintained at the injectionsite for the entire period of time.

Using the automatic injection device, e.g., autoinjector pen, of theinvention, a patient will know that the injection has finished when theindicator in the window appears in full view and stops. When theinjection is finished, the automatic injection device, e.g.,autoinjector pen, is pulled from the skin of the user. The shroud willautomatically advance over the needle tip. The patient may press acotton ball over the injection site and hold it, e.g., for 10 seconds.The patient should not rub the injection site, and should not be alarmedif there is slight bleeding. Following injection, the automaticinjection device, e.g., autoinjector pen, should be disposed of, suchthat the patient tries not to touch the needle. The needle sleeveprevents the patient from touching the needle.

It should be noted that any of the instructions recited in the methodsfor using the automatic injection device of the invention may beincluded in a label for the automatic injection device, e.g.,autoinjector pen, of the invention.

Methods and Compositions for Training a Recipient for Use of anAutomatic Injection Device

Another aspect of the invention pertains to methods and compositions fortraining a recipient in the use of an automatic injection device. Basedon experience in use of the device in clinical studies, particularimportant features for successful use of the device have now beendiscovered and these features can be incorporated into business methodsfor training recipients in the use of the automatic injection device.Such training methods, and compositions used in such methods, arebeneficial for communicating to an end user of the device, or to a partythat will introduce, prescribe or sell the device to an end user,important features for successful use of the device.

Moreover, the use of a demonstration automatic injection device ortrainer device that mimics the look and feel of the actual automaticinjection device but which is incapable of administering the substanceor medication, is particularly useful in training a recipient in thesuccessful use of the actual automatic injection device, since it allowsthe recipient to experience and practice the handling and control of thedevice without the possibility of inadvertently administering themedication.

Accordingly, in one aspect, the invention provides a method of traininga recipient on use of an automatic injection device, wherein theautomatic injection device comprises a needle and a medication, themethod comprising providing to the recipient:

-   -   (a) a demonstration automatic injection device which lacks the        needle and the medication; and    -   (b) instructions for using the automatic injection device.

In another aspect, the invention provides a kit for training a recipienton use of an automatic injection device, wherein the automatic injectiondevice comprises a needle and a medication, the kit comprising:

-   -   (a) a demonstration automatic injection device which lacks the        needle and the medication; and    -   (b) instructions for using the automatic injection device.

In a preferred embodiment, the recipient is a physician that prescribesthe medication contained within the automatic injection device. Inanother embodiment, the recipient is a patient that uses the medicationcontained within the automatic injection device. Other examples ofrecipients include pharmacists that dispense the automatic injectiondevice, family members or other caregivers of patients that use themedication and representatives that train physicians or patients in useof the automatic injection device.

In certain embodiments of the method, including the training methodsdescribed herein, the instructions for using the automatic injectiondevice are conveyed orally to the recipient. In other preferredembodiments, instructions are conveyed in writing (e.g., via a printeddocument) or via an audiovisual device to the recipient. In the kits ofthe invention, the instructions for using the automatic injection devicetypically are contained with a printed document or audiovisual device.Preferred audiovisual devices include VHS cassettes and DVDs.

The demonstration automatic injection device is designed to look andfeel like the actual automatic injection device, but lacks at least onecomponent necessary to allow for successful administration of amedication by an end user and most preferably at least lacks a needlesuch that inadvertent needle pricks are avoided when using thedemonstration automatic injection device. Preferably, the demonstrationautomatic injection device lacks both the needle and the medication thatis contained in the actual automatic injection device.

In another aspect, the invention provides a method of training arecipient on use of an automatic injection device, wherein the automaticinjection device comprises an activator mechanism and a medication, themethod comprising conveying to the recipient instructions to:

(a) position the automatic injection device at an injection site;

(b) engage the activator mechanism to begin injection of the medication;

(c) maintain engagement of the activator mechanism for a prescribedperiod of time to continue injection of the medication; and

(d) remove the automatic injection device from the injection site afterpassage of the prescribed period of time.

The invention also provides an audiovisual device for training arecipient on use of an automatic injection device, wherein the automaticinjection device comprises an activator mechanism and a medication, theaudiovisual device conveying to the recipient instructions to:

(a) position the automatic injection device at an injection site;

(b) engage the activator mechanism to begin injection of the medication;

(c) maintain engagement of the activator mechanism for a prescribedperiod of time to continue injection of the medication; and

(d) remove the automatic injection device from the injection site afterpassage of the prescribed period of time.

Preferably, the audiovisual device is an VHS cassette or an DVD.

In the above training methods and audiovisual devices, the instructionscan further convey that initial engagement of the activator mechanism isaccompanied by an audible sound, such as a “click”. Other examples ofaudible sounds include a bell, a buzzer or a ring-tone.

In other embodiments of the above training methods and audiovisualdevices, the instructions can further convey that completion ofinjection of the medication is accompanied by a visible indicator ofcompletion and/or the instructions can further convey that the injectionsite should be sterilized prior to positioning the automatic injectiondevice at the injection site

Other examples of instruction that can be conveyed in the above trainingmethods and audiovisual devices are described in further detail inExample 4.

In yet another aspect, the invention provides a method of training arecipient on use of an automatic injection device, wherein the automaticinjection device comprises an activator mechanism and a medication, themethod comprising conveying to the recipient instructions to:

(a) position the automatic injection device at an injection site;

(b) engage the activator mechanism to begin injection of the medication;

(c) maintain engagement of the activator mechanism to continue injectionof the medication until a visible indicator of completion is detected;and

(d) remove the automatic injection device from the injection site oncethe visible indicator of completion is detected.

The invention also provides an audiovisual device for training arecipient on use of an automatic injection device, wherein the automaticinjection device comprises an activator mechanism and a medication, theaudiovisual device conveying to the recipient instructions to:

(a) position the automatic injection device at an injection site;

(b) engage the activator mechanism to begin injection of the medication;

(c) maintain engagement of the activator mechanism to continue injectionof the medication until a visible indicator of completion is detected;and

(d) remove the automatic injection device from the injection site oncethe visible indicator of completion is detected.

Preferably, the automatic injection device comprises an indicator windowand the visible indicator of completion comprises a color indicatorappearing in the indicator window. A preferred color indicator is ayellow color indicator. Other examples of suitable color indicatorsinclude red, orange, blue, green, pink or purple color indicators. Otherexamples of visible indicators of completion include the appearance of asymbol or design in an indicator window upon completion of injection andappearance of a “pop-up” button on the automatic injection device uponcompletion of injection.

In other embodiments of the above training methods and audiovisualdevices, the instructions can further convey that engagement of theactivator mechanism should be maintained for a prescribed period of timeto continue injection of the medication and/or the instructions canfurther convey that the injection site should be sterilized prior topositioning the automatic injection device at the injection site.Preferably the prescribed period of time is 10 seconds. Anotherpreferred prescribed period of time is at least 10 seconds. In variousother embodiments, the prescribed period of time is 1 second, 2 seconds,3 seconds, 4 seconds, 5 seconds, 6 seconds, 7 seconds, 8 seconds, 9seconds, 11 seconds, 12 seconds, 13 seconds, 14 seconds, 15 seconds, 30seconds, 45 seconds or 1 minute.

In another embodiment of the above training methods and audiovisualdevices, the instructions further convey that the automatic injectiondevice should be examined for proper dosage and formulation of themedication prior to positioning the automatic injection device at theinjection site. Such examination can be done, for example, by looking atthe medication through a window present in the automatic injectiondevice that allows for visualization of the liquid medication containedin the device. Examples of examination for proper dosage and formulationinclude examining whether the medication is clear and colorless (e.g.,is not cloudy and does not contain particulate matter) and examiningwhether the level of medication is the same as or close to a “fill-line”indication visible in the window.

Other examples of instruction that can be conveyed in the above trainingmethods and audiovisual devices are described in further detail inExample 4.

VII. Methods and Compositions for Promoting Use of an AutomaticInjection Device

One aspect of the invention pertains to methods and compositions forpromoting the use of an automatic injection device. Based on the resultsof clinical studies, advantageous features of an automatic injectiondevice have now been discovered and these features can be incorporatedinto business methods for promoting the use of the automatic injectiondevice. Such promotional methods, and compositions used in such methods,are beneficial for communicating to an end user of the device, or to aparty that will introduce, prescribe or sell the device to an end user,the advantageous features of the device.

Accordingly, in one aspect, the invention provides a method of promotingan automatic injection device comprising a substance, such as amedication, to a recipient, the method comprising conveying to therecipient at least one message selected from the group consisting of:

(a) the automatic injection device is less painful for a patient to usethan a pre-filled syringe;

(b) the automatic injection device is preferred for use by patients ascompared to a pre-filled syringe;

(c) the automatic injection device is easier to use by a patient than apre-filled syringe;

(d) the automatic injection device is more convenient for a patient touse than a pre-filled syringe;

(e) the automatic injection device reduces anxiety of patients with afear of needles, as compared to a pre-filled syringe, since the needleis not visible in the device; and

(f) the automatic injection device is designed to be easy to use frominitial use of the device.

In a preferred embodiment, the message that the automatic injectiondevice is less painful for a patient to use than a pre-filled syringe isconveyed to the recipient. For example, a message that 80% of patientsin a clinical trial rated the automatic injection device as less painfulthan a pre-filled syringe can be conveyed to the recipient.

In another preferred embodiment, the message that the automaticinjection device is preferred for use by patients as compared to apre-filled syringe is conveyed to the recipient. For example, a messagethat 90% of patients in a clinical trial preferred the automaticinjection device to a pre-filled syringe can be conveyed to therecipient.

Particular structural features of the automatic injection device alsocan be conveyed to the recipient. For example, a message that theautomatic injection device comprises a five-bevel needle, as compared toa three-bevel needle for a pre-filled syringe, additionally can beconveyed to the recipient. As another example, a message that the needleis not visible in the device (i.e., not visible to the user of thedevice when the device is used as instructed) can be conveyed to therecipient.

In a preferred embodiment, the recipient is a physician that prescribesthe medication contained within the automatic injection device. Inanother embodiment, the recipient is a patient that uses the medicationcontained within the automatic injection device. Other examples ofrecipients include pharmacists that dispense the automatic injectiondevice, family members or caretakers thereof, of patients that use themedication and representatives that train physicians or patients in useof the automatic injection device.

In a preferred embodiment, the at least one message is conveyed orallyto the recipient. In another preferred embodiment, the at least onemessage is conveyed in writing to said recipient (e.g., via a printeddocument, such as a package insert). In yet another preferredembodiment, the at least one message is conveyed to the recipient via anaudiovisual device.

In another aspect, the invention provides an audiovisual device forpromoting an automatic injection device comprising a medication to arecipient, wherein the device conveys to the recipient at least onemessage selected from the group consisting of:

(a) the automatic injection device is less painful for a patient to usethan a pre-filled syringe;

(b) the automatic injection device is preferred for use by patients ascompared to a pre-filled syringe;

(c) the automatic injection device is easier to use by a patient than apre-filled syringe;

(d) the automatic injection device is more convenient for a patient touse than a pre-filled syringe;

(e) the automatic injection device reduces anxiety of patients with afear of needles, as compared to a pre-filled syringe, since the needleis not visible in the device; and

(f) the automatic injection device is designed to be easy to use frominitial use of the device.

In a preferred embodiment, the audiovisual device is a Video Home System(VHS) cassette. In another preferred embodiment, the audiovisual deviceis a Digital Video Disc (DVD).

In a preferred embodiment, the audiovisual device conveys the messagethat the automatic injection device is less painful for a patient to usethan a pre-filled syringe. For example, the audiovisual device canconvey a message that 80% of patients in a clinical trial rated theautomatic injection device as less painful than a pre-filled syringe.

In another preferred embodiment, the audiovisual device conveys themessage that the automatic injection device is preferred for use bypatients as compared to a pre-filled syringe. For example, theaudiovisual device can convey a message that 90% of patients in aclinical trial preferred the automatic injection device to a pre-filledsyringe.

The audiovisual device also can convey particular structural features ofthe automatic injection device to the recipient. For example, theaudiovisual device can convey a message that the automatic injectiondevice comprises a five-bevel needle, as compared to a three-bevelneedle for a pre-filled syringe. As another example, the audiovisualdevice can convey a message that the needle is not visible in the device(i.e., not visible to the user of the device when the device is used asinstructed).

In still other embodiments, an automatic injection device previouslydescribed in the art is used in the methods and compositions of theinvention relating to training and promoting an automatic injectiondevice. Suitable automatic injection devices have been described in theart, including but not limited to the devices described in U.S. Pat.Nos. 3,941,130; 4,261,358; 5,085,642; 5,092,843; 5,102,393; 5,267,963;6,149,626; 6,270,479; and 6,371,939.

VII. Disorders in which TNFα Activity is Detrimental which can beTreated with a TNFα Inhbitor Using an Automatic Injection Device

The automatic injection device, e.g., autoinjector pen, of the inventionmay be used in methods of treating disorders, including, in oneembodiment, disorders associated with detrimental TNF activity. In oneembodiment, the automatic injection device, e.g., autoinjector pen, isused to deliver a substance, e.g., a TNFα inhibitor, to a patient fortreatment, wherein the disorder includes, but not limited to, rheumatoidarthritis (including juvenile arthritis), Crohn's disease, psoriasis,psoriatic arthritis, and ankylosing spondylitis.

As used herein, the term “a disorder in which TNFα activity isdetrimental” is intended to include diseases and other disorders inwhich the presence of TNFα in a patient suffering from the disorder hasbeen shown to be or is suspected of being either responsible for thepathophysiology of the disorder or a factor that contributes to aworsening of the disorder. Accordingly, a disorder in which TNFαactivity is detrimental is a disorder in which inhibition of TNFαactivity is expected to alleviate the symptoms and/or progression of thedisorder. Such disorders may be evidenced, for example, by an increasein the concentration of TNFα in a biological fluid of a patientsuffering from the disorder (e.g., an increase in the concentration ofTNFα in serum, plasma, synovial fluid, etc. of the patient), which canbe detected, for example, using an anti-TNFα antibody as describedabove. There are numerous examples of disorders in which TNFα activityis detrimental which are discussed further below:

A. Autoimmune Diseases

Tumor necrosis factor has been implicated in playing a role in thepathophysiology of a variety of autoimmune diseases. For example, TNFαhas been implicated in activating tissue inflammation and causing jointdestruction in rheumatoid arthritis (see e.g., Moeller, A., et al.(1990) Cytokine 2:162-169; U.S. Pat. No. 5,231,024 to Moeller et al.;European Patent Publication No. 260 610 B1 by Moeller, A.; Tracey andCerami, supra; Arend, W. P. and Dayer, J-M. (1995) Arth. Rheum.38:151-160; Fava, R. A., et al. (1993) Clin. Exp. Immunol. 94:261-266).TNFα also has been implicated in promoting the death of islet cells andin mediating insulin resistance in diabetes (see e.g., Tracey andCerami, supra; PCT Publication No. WO 94/08609). TNFα also has beenimplicated in mediating cytotoxicity to oligodendrocytes and inductionof inflammatory plaques in multiple sclerosis (see e.g., Tracey andCerami, supra). TNFα also has been implicated in mediating cytotoxicityto oligodendrocytes and induction of inflammatory plaques in multiplesclerosis (see e.g., Tracey and Cerami, supra). Chimeric and humanizedmurine anti-hTNFα antibodies have undergone clinical testing fortreatment of rheumatoid arthritis (see e.g., Elliott, M. J., et al.(1994) Lancet 344:1125-1127; Elliot, M. J., et al. (1994) Lancet344:1105-1110; Rankin, E. C., et al. (1995) Br. J. Rheumatol.34:334-342).

TNFα antibodies, such as adalimumab, may be used to treat autoimmunediseases, in particular those associated with inflammation. Examples ofsuch autoimmune conditions include rheumatoid arthritis, rheumatoidspondylitis, osteoarthritis and gouty arthritis, allergy, multiplesclerosis, autoimmune diabetes, autoimmune uveitis and nephroticsyndrome. Other examples of autoimmune conditions include multisystemautoimmune diseases and autoimmune hearing loss.

In one embodiment of the invention, a TNFα inhibitor is used to treatautoimmune disorders such as lupus. Lupus is has been shown to beassociated with TNF activity (Shvidel et al. (2002) Hematol J. 3:32;Studnicka-Benke et al. (1996) Br J Rheumatol. 35:1067). The term “lupus”as used herein refers to a chronic, inflammatory autoimmune disordercalled lupus erythematosus that may affect many organ systems includingthe skin, joints and internal organs. Lupus is a general term whichincludes a number of specific types of lupus, including systemic lupus,lupus nephritis, and lupus cerebritis. In systemic lupus (SLE), thebody's natural defenses are turned against the body and rogue immunecells attack the body's tissues. Antibodies may be produced that canreact against the body's blood cells, organs, and tissues. This reactionleads to immune cells attacking the affected systems, producing achronic disease. Lupus nephritis, also referred to as lupus glomerulardisease, is kidney disorder that is usually a complication of SLE, andis characterized by damage to the glomerulus and progressive loss ofkidney function. Lupus cerebritis refers to another complication of SLE,which is inflammation of the brain and/or central nervous system.

Another autoimmune disease which can be treated using a TNFα antibody isCrohn's disease, which is described in more detail below in theIntestinal Disorders Section.

B. Intestinal Disorders

Tumor necrosis factor has been implicated in the pathophysiology ofinflammatory bowel disorders including Crohn's disease (see e.g., Tracyet al. (1986) Science 234:470; Sun et al. (1988) J. Clin. Invest.81:1328; MacDonald et al. (1990) Clin. Exp. Immunol. 81:301). Chimericmurine anti-hTNFα antibodies have undergone clinical testing fortreatment of Crohn's disease (van Dullemen et al. (1995)Gastroenterology 109:129). The invention includes treatment comprisingadministering a TNFα antibody obtained using the method of the inventionto treat intestinal disorders, such as idiopathic inflammatory boweldisease, using human antibodies, or antigen-binding fragments thereof.Idiopathic inflammatory bowel disease includes two syndromes, Crohn'sdisease and ulcerative colitis. In one embodiment, an antibody obtainedusing the method of the invention is also used to treat disorders oftenassociated with IBD and Crohn's disease. The term “inflammatory boweldisorder (IBD)-related disorder” or “Crohn's disease-related disorder,”as used interchangeably herein, is used to describe conditions andcomplications commonly associated with IBD and Crohn's disease.

The invention also includes a multiple-variable dose regimen comprisingadministering a TNFα antibody to treat Crohn's disease. The treatment ofCrohn's disease is based on location, extent, and severity of disease.Pharmacologic interventions include anti-inflammatory agents(aminosalicylates and corticosteroids) and immunomodulatory agents(azathioprine and 6-mercaptopurine [6-MP], cyclosporine, methotrexate[MTX], antibiotic agents, and biologic agents).C-reactive protein (CRP)and erythrocyte sedimentation rate (ESR) levels reflect non-specificacute phase reactions. Endoscopy is a primary means of diagnosingCrohn's disease. Radiologic features of Crohn's disease are shown bybarium examination includes mucosal edema, aphthous and linearulcerations, asymmetrical narrowing and strictures, and separation ofadjacent loops of bowel caused by mesenteric thickening. Abnormalitiesare focal and asymmetric. The primary histologic lesion is an aphthousulcer. Subjects with Crohn's disease can be evaluated using the Crohn'sDisease Activity Index (CDAI), which is a standard measure of theseverity of the disease with higher scores indicating more severedisease activity.

Examples of Crohn's disease-related disorders that can be treated usingthe methods of the invention include fistulas in the bladder, vagina,and skin; bowel obstructions; abscesses; nutritional deficiencies;complications from corticosteroid use; inflammation of the joints;erythem nodosum; pyoderma gangrenosum; and lesions of the eye. Otherdisorders commonly associated with Crohn's disease includeCrohn's-related arthralgias, fistulizing Crohn's, indeterminant colitis,and pouchitis.

C. Spondyloarthropathies

TNFα has been implicated in the pathophysiology of a wide variety ofdisorders, including inflammatory diseases such as spondyloarthopathies(see e.g., Moeller et al. (1990) Cytokine 2:162; U.S. Pat. No.5,231,024; European Patent Publication No. 260 610). The inventionprovides multiple-variable dose methods for inhibiting TNFα activity ina patient suffering from a spondyloarthropathy, which method comprisesadministering to the patient an antibody, antibody portion, such thatTNFα activity in the patient suffering from a spondyloarthropathy isinhibited.

As used herein, the term “spondyloarthropathy” or“spondyloarthropathies” is used to refer to any one of several diseasesaffecting the joints of the spine, wherein such diseases share commonclinical, radiological, and histological features. A number ofspondyloarthropathies share genetic characteristics, i.e. they areassociated with the HLA-B27 allele. In one embodiment, the termspondyloarthropathy is used to refer to any one of several diseasesaffecting the joints of the spine, excluding ankylosing spondylitis,wherein such diseases share common clinical, radiological, andhistological features. Examples of spondyloarthropathies includeankylosing spondylitis, psoriatic arthritis/spondylitis, enteropathicarthritis, reactive arthritis or Reiter's syndrome, and undifferentiatedspondyloarthropathies. Examples of animal models used to studyspondyloarthropathies include ank/ank transgenic mice, HLA-B27transgenic rats (see Taurog et al. (1998) The Spondylarthritides.Oxford:Oxford University Press).

The automatic injection device of the invention can also be used totreat patients who are at risk of developing a spondyloarthropathy usingmultiple-variable dose methods. Examples of patients who are at risk ofhaving spondyloarthropathies include humans suffering from arthritis.Spondyloarthropathies can be associated with other forms of arthritis,including rheumatoid arthritis. In one embodiment of the invention,antibodies are used in multiple-variable dose methods to treat a patientwho suffers from a spondyloarthropathy associated with rheumatoidarthritis. Examples of spondyloarthropathies that can be treated with aTNFα antibody are described below:

1. Ankylosing Spondylitis (AS)

Tumor necrosis factor has been implicated in the pathophysiology ofankylosing spondylitis (see Verjans et al. (1991) Arthritis Rheum.34:486; Verjans et al. (1994) Clin Exp Immunol. 97:45; Kaijtzel et al.(1999) Hum Immunol. 60:140). Ankylosing spondylitis (AS) is aninflammatory disorder involving inflammation of one or more vertebrae.AS is a chronic inflammatory disease that affects the axial skeletonand/or peripheral joints, including joints between the vertebrae of thespine and sacroiliac joints and the joints between the spine and thepelvis. AS can eventually cause the affected vertebrae to fuse or growtogether. Spondyarthropathies, including AS, can be associated withpsoriatic arthritis (PsA) and/or inflammatory bowel disease (IBD),including ulcerative colitis and Crohn's disease.

Early manifestations of AS can be determined by radiographic tests,including CT scans and MRI scans. Early manifestations of AS ofteninclude scroiliitis and changes in the sacroliac joints as evidenced bythe blurring of the cortical margins of the subchrondral bone, followedby erosions and sclerosis. Fatigue has also been noted as a commonsymptom of AS (Duffy et al. (2002) ACR 66th Annual Scientific MeetingAbstract). Accordingly, multiple-variable dose methods comprisingadministering an antibody, or antigen-binding fragment thereof, of theinvention can be used to treat AS.

In one embodiment, the multiple-variable dose method of the invention isused to treat a spondyloarthropathy associated with IBD, including AS.AS is often treated with nonsteroidal anti-inflammatory medications(NSAIDs), such as aspirin or indomethacin. Accordingly, a TNFα antibodyused in the multiple-variable dose method of the invention may also beadministered in combination with agents commonly used to reduceinflammation and pain commonly associated with ankylosing spondylitis.

2. Psoriatic Arthritis

Tumor necrosis factor has been implicated in the pathophysiology ofpsoriatic arthritis (PsA) (Pansch et al. (1998) Ann Rheum Dis. 57:691;Ritchlin et al. (1998) J Rheumatol. 25:1544). As referred to herein,psoriatic arthritis or psoriasis associated with the skin, refers tochronic inflammatory arthritis which is associated with psoriasis, whichis a common chronic skin condition that causes red patches on the body.About 1 in 20 individuals with psoriasis will develop arthritis alongwith the skin condition, and in about 75% of cases, psoriasis precedesthe arthritis. PsA exhibits itself in a variety of ways, ranging frommild to severe arthritis, wherein the arthritis usually affects thefingers and the spine. When the spine is affected, the symptoms aresimilar to those of ankylosing spondylitis, as described above. The TNFαantibody, or antigen-binding fragment thereof, obtained using theinvention can be used for treatment of PsA.

PsA is sometimes associated with arthritis mutilans. Arthritis mutilansrefers to a disorder that is characterized by excessive bone erosionresulting in a gross, erosive deformity that mutilates the joint. In oneembodiment, antibodies obtained using the method of the invention areused to treat arthritis mutilans.

3. Reactive Arthritis/Reiter's Syndrome

Tumor necrosis factor has been implicated in the pathophysiology ofreactive arthritis, which is also referred to as Reiter's syndrome(Braun et al. (1999) Arthritis Rheum. 42(10):2039). Reactive arthritis(ReA) refers to arthritis that complicates an infection elsewhere in thebody, often following enteric or urogenital infections. ReA is oftencharacterized by certain clinical symptoms, including inflammation ofthe joints (arthritis), urethritis, conjunctivitis, and lesions of theskin and mucous membranes. In addition, ReA can occurs followinginfection with a sexually transmitted disease or dysenteric infection,including chlamydia, campylobacter, salmonella, or yersinia.Accordingly, antibodies obtained using the method of the invention maybe used to treat ReA.

4. Undifferentiated Spondyloarthropathies

In one embodiment, antibodies obtained using methods of the inventionare used to treat patients suffering from undifferentiatedspondyloarthropathies (see Zeidler et al. (1992) Rheum Dis Clin NorthAm. 18:187). Other terms used to describe undifferentiatedspondyloarthropathies include seronegative oligoarthritis andundifferentiated oligoarthritis. Undifferentiated spondyloarthropathies,as used herein, refers to a disorder wherein the patient demonstratesonly some of the symptoms associated with a spondyloarthropathy. Thiscondition is usually observed in young adults who do not have IBD,psoriasis, or the classic symptoms of AS or Reiter's syndrome. In someinstances, undifferentiated spondyloarthropathies may be an earlyindication of AS. In one embodiment, the invention comprisesadministering a TNFα antibody, or antigen-binding fragment thereof,obtained using the claimed process to treat undifferentiatedspondyloarthropathies.

D. Skin and Nail Disorders

Tumor necrosis factor has been implicated in the pathophysiology of skinand nail disorders. The term “skin disorder” or “skin disease” as usedinterchangeably herein, refers to abnormalities, other than injurywounds, of the skin that have induced a state of inflammation. In oneembodiment, the skin disorder of the invention is an inflammatory skindisorder, wherein the skin is characterized by capillary dilatation,leukocytic infiltration, redness, heat, and/or pain. Examples of skindisorders include, but are not limited to, psoriasis, pemphigusvulgaris, scleroderma, atopic dermatitis, sarcoidosis, erythema nodosum,hidradenitis suppurative, lichen planus, Sweet's syndrome, and vitiligo.As used herein, the term “skin and nail disorder in which TNFα activityis detrimental” is intended to include skin and/or nail disorders andother disorders in which the presence of TNFα in a patient sufferingfrom the disorder has been shown to be or is suspected of being eitherresponsible for the pathophysiology of the disorder or a factor thatcontributes to a worsening of the disorder, e.g., psoriasis.Accordingly, skin and nail disorders in which TNFα activity isdetrimental are disorders in which inhibition of TNFα activity isexpected to alleviate the symptoms and/or progression of the disorder.The use of the antibodies, antibody portions, and other TNFα inhibitorsof the invention in the treatment of specific skin and nail disorders isdiscussed further below. In certain embodiments, the treatment method ofthe invention is performed in combination with another therapeuticagent, as described below. In one embodiment, the antibodies obtainedusing the method of the invention comprising administering a TNFαantibody in combination with another therapeutic agent is used for thetreatment of psoriasis and the treatment of psoriasis associated witharthritis.

1. Psoriasis

Tumor necrosis factor has been implicated in the pathophysiology ofpsoriasis (Takematsu et al. (1989) Arch Dermatol Res. 281:398; Victorand Gottlieb (2002) J Drugs Dermatol. 1:264). The term “psoriasis” asused herein, refers to skin disorders associated with epidermalhyperplasia. Examples of psoriasis include, but are not limited to,chronic plaque psoriasis, guttate psoriasis, inverse psoriasis, pustularpsoriasis, psoriasis vulgaris, and erythrodermic psoriasis. Psoriasiscan also be associated with other inflammatory disorders, includinginflammatory bowel disease (IBD) and rheumatoid arthritis (RA).

Psoriasis is described as a skin inflammation (irritation and redness)characterized by frequent episodes of redness, itching, and thick, dry,silvery scales on the skin. In particular, lesions are formed whichinvolve primary and secondary alterations in epidermal proliferation,inflammatory responses of the skin, and an expression of regulatorymolecules such as lymphokines and inflammatory factors. Psoriatic skinis morphologically characterized by an increased turnover of epidermalcells, thickened epidermis, abnormal keratinization, inflammatory cellinfiltrates into the epidermis and polymorphonuclear leukocyte andlymphocyte infiltration into the epidermis layer resulting in anincrease in the basal cell cycle. Psoriasis often involves the nails,which frequently exhibit pitting, separation of the nail, thickening,and discoloration. Psoriasis is often associated with other inflammatorydisorders, for example arthritis, including rheumatoid arthritis,inflammatory bowel disease (IBD), and Crohn's disease. Approximately onethird of patients with psoriasis also have psoriatic arthritis (PsA)which, as described above, causes stiffness, swelling of the joints,pain, and reduced range of motion (Greaves et al. (1995) N. Eng. J. Med.332:581).

Evidence of psoriasis is most commonly seen on the trunk, elbows, knees,scalp, skin folds, or fingernails, but it may affect any or all parts ofthe skin. Normally, it takes about a month for new skin cells to move upfrom the lower layers to the surface. In psoriasis, this process takesonly a few days, resulting in a build-up of dead skin cells andformation of thick scales. Symptoms of psoriasis include: skin patches,that are dry or red, covered with silvery scales, raised patches ofskin, accompanied by red borders, that may crack and become painful, andthat are usually located on the elbows, knees, trunk, scalp, and hands;skin lesions, including pustules, cracking of the skin, and skinredness; joint pain or aching which may be associated with of arthritis,e.g., psoriatic arthritis.

Treatment for psoriasis often includes a topical corticosteroids,vitamin D analogs, and topical or oral retinoids, or combinationsthereof. In one embodiment, the TNFα antibody of the invention isadministered in combination with or the presence of one of these commontreatments. Additional therapeutic agents that can be combined with theTNFα antibody obtained using the methods of the invention for treatmentof psoriasis are described in more detail below.

The diagnosis of psoriasis is usually based on the appearance of theskin. Additionally a skin biopsy, or scraping and culture of skinpatches may be needed to rule out other skin disorders. An x-ray may beused to check for psoriatic arthritis if joint pain is present andpersistent.

Improvements in psoriasis in a patient can be monitored by the patient'sPsoriasis Area and Severity Index Score (PASI). The method fordetermining the PASI has been described in Fredriksson and Pettersson(1978) Dermatologica 157:238 and Marks et al. (1989) Arch Dermatol125:235. Briefly, the index is based on evaluation of four anatomicsites, including the head, upper extremities, trunk, and lowerextremities, for erythema, induration, and desquamation using a 5 pointscale (0=no symptoms; 1=slight; 2=moderate; 3=marked; 4=very marked).Based on the extent of lesions in a given anatomic site, the areaaffected is assigned a numerical value (0=0; 1=<10%; 2=10-29%; 3=30-49%;4=50-69%; 5=70=89%; 6=90-100%). The PASI score is then calculated,wherein the possible range of PASI score is 0.0 to 72.0 with the highestscore representing complete erythroderma of the severest degree.

In one embodiment of the invention, a TNFα antibody is used for thetreatment of psoriasis, including chronic plaque psoriasis, guttatepsoriasis, inverse psoriasis, pustular psoriasis, pemphigus vulgaris,erythrodermic psoriasis, psoriasis associated with inflammatory boweldisease (IBD), and psoriasis associated with rheumatoid arthritis (RA).In another embodiment, a TNFα antibody, such as adalimumab, is used totreat patients who have psoriasis in combination with PsA. Specifictypes of psoriasis included in the treatment methods of the inventionare described in detail below:

a. Chronic Plaque Psoriasis

Tumor necrosis factor has been implicated in the pathophysiology ofchronic plaque psoriasis (Asadullah et al. (1999) Br J Dermatol.141:94).Chronic plaque psoriasis (also referred to as psoriasis vulgaris) is themost common form of psoriasis. Chronic plaque psoriasis is characterizedby raised reddened patches of skin, ranging from coin-sized to muchlarger. In chronic plaque psoriasis, the plaques may be single ormultiple, they may vary in size from a few millimeters to severalcentimeters. The plaques are usually red with a scaly surface, andreflect light when gently scratched, creating a “silvery” effect.Lesions (which are often symmetrical) from chronic plaque psoriasisoccur all over body, but with predilection for extensor surfaces,including the knees, elbows, lumbosacral regions, scalp, and nails.Occasionally chronic plaque psoriasis can occur on the penis, vulva andflexures, but scaling is usually absent. Diagnosis of patients withchronic plaque psoriasis is usually based on the clinical featuresdescribed above. In particular, the distribution, color and typicalsilvery scaling of the lesion in chronic plaque psoriasis arecharacteristic of chronic plaque psoriasis.

b. Guttate Psoriasis

Guttate psoriasis refers to a form of psoriasis with characteristicwater drop shaped scaly plaques. Flares of guttate psoriasis generallyfollow an infection, most notably a streptococcal throat infection.Diagnosis of guttate psoriasis is usually based on the appearance of theskin, and the fact that there is often a history of recent sore throat.

c. Inverse Psoriasis

Inverse psoriasis is a form of psoriasis in which the patient hassmooth, usually moist areas of skin that are red and inflammed, which isunlike the scaling associated with plaque psoriasis. Inverse psoriasisis also referred to as intertiginous psoriasis or flexural psoriasis.Inverse psoriasis occurs mostly in the armpits, groin, under the breastsand in other skin folds around the genitals and buttocks, and, as aresult of the locations of presentation, rubbing and sweating canirriate the affected areas.

d. Pustular Psoriasis

Pustular psoriasis, also referred to as palmar plantar psoriasis, is aform of psoriasis that causes pus-filled blisters that vary in size andlocation, but often occur on the hands and feet. The blisters may belocalized, or spread over large areas of the body. Pustular psoriasiscan be both tender and painful, can cause fevers.

e. Other Psoriasis Disorders

Other examples of psoriatic disorders that can be treated with a TNFαantibody delivered using the methods of the invention includeerythrodermic psoriasis, vulgaris, psoriasis associated with IBD, andpsoriasis associated with arthritis, including rheumatoid arthritis.

2. Pemphigus Vulgaris

Pemphigus vulgaris is a serious autoimmune systemic dermatologic diseasethat often affects the oral mucous membrane and skin. The pathogenesisof pemphigus vulgaris is thought to be an autoimmune process that isdirected at skin and oral mucous membrane desmosomes. Consequentially,cells do not adhere to each other. The disorder manifests as largefluid-filled, rupture-prone bullae, and has a distinctive histologicappearance. Anti-inflammatory agents are the only effective therapy forthis disease that has a high mortality rate. Complications that arise inpatients suffering from pemphigus vulgaris are intractable pain,interference with nutrition and fluid loss, and infections.

3. Atopic Dermatitis/Eczema

Atopic dermatitis (also referred to as eczema) is a chronic skindisorder categorized by scaly and itching plaques. People with eczemaoften have a family history of allergic conditions like asthma, hayfever, or eczema. Atopic dermatitis is a hypersensitivity reaction(similar to an allergy) which occurs in the skin, causing chronicinflammation. The inflammation causes the skin to become itchy andscaly. Chronic irritation and scratching can cause the skin to thickenand become leathery-textured. Exposure to environmental irritants canworsen symptoms, as can dryness of the skin, exposure to water,temperature changes, and stress.

Subjects with atopic dermatitis can be identified by certain symptoms,which often include intense itching, blisters with oozing and crusting,skin redness or inflammation around the blisters, rash, dry, leatheryskin areas, raw areas of the skin from scratching, and eardischarges/bleeding.

4. Sarcoidosis

Sarcoidosis is a disease in which granulomatous inflammation occurs inthe lymph nodes, lungs, liver, eyes, skin, and/or other tissues.Sarcoidosis includes cutaneous sarcoidosis (sarcoidosis of the skin) andnodular sarcoidosis (sarcoidosis of the lymph nodes). Patients withsarcoidosis can be identified by the symptoms, which often includegeneral discomfort, uneasiness, or an ill feeling; fever; skin lesions.

5. Erythema Nodosum

Erythema nodosum refers to an inflammatory disorder that ischaracterized by tender, red nodules under the skin, typically on theanterior lower legs. Lesions associated with erythema nodosum oftenbegin as flat, but firm, hot red painful lumps (approximately an inchacross). Within a few days the lesions may become purplish, and thenover several weeks fade to a brownish flat patch.

In some instances, erythema nodosum may be associated with infectionsincluding, streptococcus, coccidioidomycosis, tuberculosis, hepatitis B,syphilis, cat scratch disease, tularemia, yersinia, leptospirosispsittacosis, histoplasmosis, mononucleosis (EBV). In other instances,erythema nodosum may be associated with sensitivity to certainmedications including, oralcontraceptives, penicillin, sulfonamides,sulfones, barbiturates, hydantoin, phenacetin, salicylates, iodides, andprogestin. Erythema nodosum is often associated with other disordersincluding, leukemia, sarcoidosis, rheumatic fever, and ulcerativecolitis.

Symptoms of erythema nodosum usually present themselves on the shins,but lesions may also occur on other areas of the body, including thebuttocks, calves, ankles, thighs and upper extremities. Other symptomsin patients with erythema nodosum can include fever and malaise.

6. Hidradenitis Suppurative

Hidradenitis suppurativa refers to a skin disorder in which swollen,painful, inflamed lesions or lumps develop in the groin and sometimesunder the arms and under the breasts. Hidradenitis suppurativa occurswhen apocrine gland outlets become blocked by perspiration or are unableto drain normally because of incomplete gland development. Secretionstrapped in the glands force perspiration and bacteria into surroundingtissue, causing subcutaneous induration, inflammation, and infection.Hidradenitis suppurativa is confined to areas of the body that containapocrine glands. These areas are the axillae, areola of the nipple,groin, perineum, circumanal, and periumbilical regions.

7. Lichen Planus

Tumor necrosis factor has been implicated in the pathophysiology oflichen planus (Sklavounou et al. (2000) J Oral Pathol Med. 29:370).Lichen planus refers to a disorder of the skin and the mucous membranesresulting in inflammation, itching, and distinctive skin lesions. Lichenplanus may be associated with hepatitis C or certain medications.

8. Sweet's Syndrome

Inflammatory cytokines, including tumor necrosis factor, have beenimplicated in the pathophysiology of Sweet's syndrome (Reuss-Borst etal. (1993) Br J Haematol. 84:356). Sweet's syndrome, which was describedby R. D. Sweet in 1964, is characterized by the sudden onset of fever,leukocytosis, and cutaneous eruption. The eruption consists of tender,erythematous, well-demarcated papules and plaques which show denseneutrophilic infiltrates microscopically. The lesions may appearanywhere, but favor the upper body including the face. The individuallesions are often described as pseudovesicular or pseudopustular, butmay be frankly pustular, bullous, or ulcerative. Oral and eyeinvolvement (conjunctivitis or episcleritis) have also been frequentlyreported in patients with Sweet's syndrome. Leukemia has also beenassociated with Sweet's syndrome.

9. Vitiligo

Vitiligo refers to a skin condition in which there is loss of pigmentfrom areas of skin resulting in irregular white patches with normal skintexture. Lesions characteristic of vitiligo appear as flat depigmentedareas. The edges of the lesions are sharply defined but irregular.Frequently affected areas in patients with vitiligo include the face,elbows and knees, hands and feet, and genitalia.

10. Scleroderma

Tumor necrosis factor has been implicated in the pathophysiology ofscleroderma (Tutuncu et al. (2002) Clin Exp Rheumatol. 20(6 Suppl 28):S146; Mackiewicz et al. (2003) Clin Exp Rheumatol. 21:41; Murota et al.(2003) Arthritis Rheum. 48:1117). Scleroderma refers to a a diffuseconnective tissue disease characterized by changes in the skin, bloodvessels, skeletal muscles, and internal organs. Scleroderma is alsoreferred to as CREST syndrome or progressive systemic sclerosis, andusually affects people between the ages 30-50. Women are affected moreoften than men.

The cause of scleroderma is unknown. The disease may produce local orsystemic symptoms. The course and severity of the disease varies widelyin those affected. Excess collagen deposits in the skin and other organsproduce the symptoms. Damage to small blood vessels within the skin andaffected organs also occurs. In the skin, ulceration, calcification, andchanges in pigmentation may occur. Systemic features may includefibrosis and degeneration of the heart, lungs, kidneys andgastrointestinal tract.

Patients suffering from scleroderma exhibit certain clinical features,including, blanching, blueness, or redness of fingers and toes inresponse to heat and cold (Raynaud's phenomenon), pain, stiffness, andswelling of fingers and joints, skin thickening and shiny hands andforearm, esophageal reflux or heartburn, difficulty swallowing, andshortness of breath. Other clinical symptoms used to diagnosescleroderma include, an elevated erythrocyte sedimentaion rate (ESR), anelevated rheumatoid factor (RF), a positive antinuclear antibody test,urinalysis that shows protein and microscopic blood, a chest X-ray thatmay show fibrosis, and pulmonary function studies that show restrictivelung disease.

11. Nail Disorders

Nail disorders include any abnormality of the nail. The term “naildisorder” or “nail disease” as used herein, refers to conditions whereinthe fingernails or toenails to abnormal color, shape, texture, orthickness. Specific nail disorders include, but are not limited to,pitting, koilonychia, Beads lines, spoon nails, onycholysis, yellownails, pterygium (seen in lichen planus), and leukonychia. Pitting ischaracterised by the presence of small depressions on the nail surface.Ridges or linear elevations can develop along the nail occurring in a“lengthwise” or “crosswise” direction. Beau's lines are lineardepressions that occur “crosswise” (transverse) in the fingernail.Leukonychia describes white streaks or spots on the nails. Koilonychiais an abnormal shape of the fingernail where the nail has raised ridgesand is thin and concave Koilonychia is often associated with irondeficiency.

Nail disorders that can be treated with the TNFα antibody of theinvention also include psoriatic nails. Psoriatic nails include changesin nails that are attributable to psoriasis. In some instances psoriasismay occur only in the nails and nowhere else on the body. Psoriaticchanges in nails range from mild to severe, generally reflecting theextent of psoriatic involvement of the nail plate, nail matrix, i.e.,tissue from which the nail grows, nail bed, i.e., tissue under the nail,and skin at the base of the nail. Damage to the nail bed by the pustulartype of psoriasis can result in loss of the nail. Nail changes inpsoriasis fall into general categories that may occur singly or alltogether. In one category of psoriatic nails, the nail plate is deeplypitted, probably due to defects in nail growth caused by psoriasis. Inanother category, the nail has a yellow to yellow-pink discoloration,probably due to psoriatic involvement of the nail bed. A third subtypeof psoriatic nails is characterized by white areas, which appear underthe nail plate. The white areas are actually air bubbles marking spotswhere the nail plate is becoming detached from the nail bed. There mayalso be reddened skin around the nail. A fourth category is evidenced bythe nail plate crumbling in yellowish patches, i.e., onychodystrophy,probably due to psoriatic involvement in the nail matrix. A fifthcategory is characterized by the loss of the nail in its entirety due topsoriatic involvement of the nail matrix and nail bed.

Antibodies obtained using the method of the invention can also be usedto treat nail disorders often associated with lichen planus. Nails inpatients with lichen planus often show thinning and surface roughness ofthe nail plate with longitudinal ridges or pterygium.

The antibodies obtained using the invention can be used to treat naildisorders, such as those described herein. Often nail disorders areassociated with skin disorders. In one embodiment, the inventionincludes treatment for nail disorders using a TNFα antibody and themethods and compositions of the invention. In another embodiment, thenail disorder is associated with another disorder, including a skindisorder such as psoriasis. In another embodiment, the disorderassociated with a nail disorder is arthritis, including psoriaticarthritis.

12. Other Skin and Nail Disorders

Antibodies obtained using the method of the invention can be used totreat other skin and nail disorders, such as chronic actinic dermatitis,bullous pemphigoid, and alopecia areata. Chronic actinic dermatitis(CAD) is also referred to as photosensitivity dermatitis/actinicreticuloid syndrome (PD/AR). CAD is a condition in which the skinbecomes inflamed, particularly in areas that have been exposed tosunlight or artificial light. Commonly, CAD patients have allergies tocertain substances that come into contact with their skin, particularlyvarious flowers, woods, perfumes, sunscreens and rubber compounds.Bullous pemphigoid refers to a skin disorder characterized by theformation of large blisters on the trunk and extremities. Alopeciaareata refers to hair loss characterized by round patches of completebaldness in the scalp or beard.

E. Other TNF α-Related Disorders

In one embodiment, the invention features a multiple-variable dosemethod for treating a TNFα-related disorder in which TNFα activity isdetrimental, comprising administering to a patient a TNFα antibody, suchthat said TNFα-related disorder is treated. Examples of TNFα-relateddisorders in which TNFα activity is detrimental, are discussed furtherbelow.

1. Juvenile Arthritis

Tumor necrosis factor has been implicated in the pathophysiology ofjuvenile arthritis, including juvenile rheumatoid arthritis (Grom et al.(1996) Arthritis Rheum. 39:1703; Mangge et al. (1995) Arthritis Rheum.8:211). In one embodiment, a TNFα antibody is used to treat juvenilerheumatoid arthritis using the methods and compositions of theinvention.

The term “juvenile rheumatoid arthritis” or “JRA” as used herein refersto a chronic, inflammatory disease that occurs before age 16 that maycause joint or connective tissue damage. JRA is also referred to asjuvenile chronic polyarthritis and Still's disease.

JRA causes joint inflammation and stiffness for more than 6 weeks in achild of 16 years of age or less. Inflammation causes redness, swelling,warmth, and soreness in the joints. Any joint can be affected andinflammation may limit the mobility of affected joints. One type of JRAcan also affect the internal organs.

JRA is often classified into three types by the number of jointsinvolved, the symptoms, and the presence or absence of certainantibodies found by a blood test. These classifications help thephysician determine how the disease will progress and whether theinternal organs or skin is affected. The classifications of JRA includethe following:

a. Pauciarticular JRA, wherein four or fewer joints are affected.Pauciarticular is the most common form of JRA, and typically affectslarge joints, such as the knees.

b. Polyarticular HRA, wherein five or more joints are affected. Thesmall joints, such as those in the hands and feet, are most commonlyinvolved, but the disease may also affect large joints.

c. Systemic JRA is characterized by joint swelling, fever, a light skinrash, and may also affect internal organs such as the heart, liver,spleen, and lymph nodes. Systemic JRA is also referred to as it Still'sdisease. A small percentage of these children develop arthritis in manyjoints and can have severe arthritis that continues into adulthood.

2. Endometriosis

Tumor necrosis factor has been implicated in the pathophysiology ofendometriosis, as women with endometriosis have elevated peritoneallevels of TNF (Eisermann et al. (1988) Fertil Steril 50:573; Halme(1989) Am J Obstet Gynecol 161:1718; Mori et al. (1991) Am J ReprodImmunol 26:62; Taketani et al. (1992) Am J Obstet Gynecol 167:265;Overton et al. (1996) Hum Reprod 1996; 11:380). In one embodiment, theTNFα antibody may be used to treat endometriosis. The term“endometriosis” as used herein refers to a condition in which the tissuethat normally lines the uterus (endometrium) grows in other areas of thebody, causing pain, irregular bleeding, and frequently infertility.

3. Prostatitis

Tumor necrosis factor has been implicated in the pathophysiology ofprostatitis, as men with chronic prostatitis and chronic pelvic painhave significantly higher levels of TNF and IL-1 in semen compared tocontrols (Alexander et al. (1998) Urology 52:744; Nadler et al. (2000) JUrol 164:214; Orhan et al. (2001) Int J Urol 8:495)

Furthermore, in a rat model of prostatitis TNF levels were alsoincreased in comparison to controls (Asakawa et al. (2001) HinyokikaKiyo 47:459; Harris et al. (2000) Prostate 44:25). In one embodiment,the TNFα antibody of the invention is used to treat prostatitis.

The term “prostatitis” as used herein refers to an inflammation of theprostate. Prostatitis is also referred to as pelvic pain syndrome.Prostatitis manifests itself in a variety of forms, includingnonbacterial prostatitis, acute prostatitis, bacterial prostatitis, andacute prostatitis. Acute prostatitis refers to an inflammation of theprostate gland that develops suddenly. Acute prostatitis is usuallycaused by a bacterial infection of the prostate gland. Chronicprostatitis is an inflammation of the prostate gland that developsgradually, continues for a prolonged period, and typically has subtlesymptoms. Chronic prostatitis is also usually caused by a bacterialinfection

4. Choroidal Neovascularization

Tumor necrosis factor has been implicated in the pathophysiology ofchoroidal neovascularization. For example, in surgically excisedchoroidal neovascular membranes, neovascular vessels stained positivefor both TNF and IL-1 (Oh H et al. (1999) Invest Ophthalmol Vis Sci40:1891). In one embodiment, the TNFα antibody is used to treatchoroidal neovascularization. The term “choroidal neovascularization” asused herein refers to the growth of new blood vessels that originatefrom the choroid through a break in the Bruch membrane into thesub-retinal pigment epithelium (sub-RPE) or subretinal space. Choroidalneovascularization (CNV) is a major cause of visual loss in patientswith the condition.

5. Sciatica

Tumor necrosis factor has been implicated in the pathophysiology ofsciatica (Ozaktay et al. (2002) Eur Spine J. 11:467; Brisby et al.(2002) Eur Spine J. 11:62). In one embodiment, the TNFα antibody of theinvention is used to treat sciatica. The term “sciatica” as used hereinrefers to a condition involving impaired movement and/or sensation inthe leg, caused by damage to the sciatic nerve. Sciatica is alsocommonly referred to as neuropathy of the sciatic nerve and sciaticnerve dysfunction. Sciatica is a form of peripheral neuropathy. Itoccurs when there is damage to the sciatic nerve, located in the back ofthe leg. The sciatic nerve controls the muscles of the back of the kneeand lower leg and provides sensation to the back of the thigh, part ofthe lower leg and the sole of the foot. Sciatica can be indicative ofanother disorder, including a lumbar herniated disc, spinal stenosis,degenerative disc disease, isthmic spondyloisthesis and piniformissyndrome.

6. Sjogren's Syndrome

Tumor necrosis factor has been implicated in the pathophysiology ofSjogren's syndrome (Koski et al. (2001) Clin Exp Rheumatol. 19:131). Inone embodiment, the TNFα antibody of the invention is used to treatSjogren's syndrome. The term “Sjogren's syndrome” as used herein refersto a systemic inflammatory disorder characterized by dry mouth,decreased tearing, and other dry mucous membranes, and is oftenassociated with autoimmune rheumatic disorders, such as rheumatoidarthritis. Dryness of the eyes and mouth are the most common symptoms ofthis syndrome. The symptoms may occur alone, or with symptoms associatedwith rheumatoid arthritis or other connective tissue diseases. There maybe an associated enlargement of the salivary glands. Other organs maybecome affected. The syndrome may be associated with rheumatoidarthritis, systemic lupus erythematosus, scleroderma, polymyositis, andother diseases.

7. Uveitis

Tumor necrosis factor has been implicated in the pathophysiology ofuveitis (Wakefield and Lloyd (1992) Cytokine 4:1; Woon et al. (1998)Curr Eye Res. 17:955). In one embodiment, the TNFα antibody of theinvention is used to treat uveitis. The term “uveitis” as used hereinrefers to an inflammation of the the uvea, which is the layer betweenthe sclera and the retina, which includes the iris, ciliary body, andthe choroid. Uveitis is also commonly referred to as iritis, parsplanitis, chroiditis, chorioretinitis, anterior uveitis, and posterioruveitis. The most common form of uveitis is anterior uveitis, whichinvolves inflammation in the front part of the eye, which is usuallyisolated to the iris. This condition is often called iritis. In oneembodiment, the term uveitis refers to an inflammation of the the uveawhich excludes inflammation associated with an autoimmune disease, i.e.,excludes autoimmune uveitis.

8. Wet Macular Degeneration

Tumor necrosis factor has been implicated in the pathophysiology of wetmacular degeneration. In one embodiment, the TNFα antibody of theinvention is used to treat wet macular degeneration. The term “wetmacular degeneration” as used herein refers to a disorder that affectsthe macula (the central part of the retina of the eye) and causesdecreased visual acuity and possible loss of central vision. Patientswith wet macular degeneration develop new blood vessels under theretina, which causes hemorrhage, swelling, and scar tissue.

9. Osteoporosis

Tumor necrosis factor has been implicated in the pathophysiology ofosteoporosis, (Tsutsumimoto et al. (1999) J Bone Miner Res. 14:1751).Osteoporosis is used to refer to a disorder characterized by theprogressive loss of bone density and thinning of bone tissue.Osteoporosis occurs when the body fails to form enough new bone, or whentoo much old bone is reabsorbed by the body, or both. The TNFα antibody,or antigen-binding fragment thereof, of the invention can be used totreat osteoporosis.

10. Osteoarthritis

Tumor necrosis factor has been implicated in the pathophysiology ofosteoarthritis, (Venn et al. (1993) Arthritis Rheum. 36:819; Westacottet al. (1994) J Rheumatol. 21:1710). Osteoarthritis (OA) is alsoreferred to as hypertrophic osteoarthritis, osteoarthrosis, anddegenerative joint disease. OA is a chronic degenerative disease ofskeletal joints, which affects specific joints, commonly knees, hips,hand joints and spine, in adults of all ages. OA is characterized by anumber of the following manifestations including degeneration andthinning of the articular cartilage with associated development of“ulcers” or craters, osteophyte formation, hypertrophy of bone at themargins, and changes in the synovial membrane and enlargement ofaffected joints. Furthermore, osteoarthritis is accompanied by pain andstiffness, particularly after prolonged activity. The antibody, orantigen-binding fragment thereof, of the invention can be used to treatosteoarthritis. Characteristic radiographic features of osteoarthritisinclude joint space narrowing, subchondral sclerosis, osteophytosis,subchondral cyst formation, loose osseous body (or “joint mouse”).

Medications used to treat osteoarthritis include a variety ofnonsteroidal, anti-inflammatory drugs (NSAIDs). In addition, COX 2inhibitors, including Celebrex, Vioxx, and Bextra, and Etoricoxib, arealso used to treat OA. Steroids, which are injected directly into thejoint, may also be used to reduce inflammation and pain. In oneembodiment of the invention, TNFα antibodies of the invention areadministered in combination with a NSAIDs, a COX2 inhibitor, and/orsteroids.

11. Other

The methods of the invention also can be used to treat various otherdisorders in which TNFα activity is detrimental. Examples of otherdiseases and disorders in which TNFα activity has been implicated in thepathophysiology, and thus which can be treated using an antibody, orantibody portion, of the invention, include inflammatory bone disorders,bone resorption disease, coagulation disturbances, burns, reperfusioninjury, keloid formation, scar tissue formation, pyrexia, periodontaldisease, obesity, radiation toxicity, age-related cachexia, Alzheimer'sdisease, brain edema, inflammatory brain injury, cancer, chronic fatiguesyndrome, dermatomyositis, drug reactions, such as Stevens-Johnsonsyndrome and Jarisch-Herxheimer reaction, edema in and/or around thespinal cord, familial periodic fevers, Felty's syndrome, fibrosis,glomerulonephritides (e.g. post-streptococcal glomerulonephritis or IgAnephropathy), loosening of prostheses, microscopic polyangiitis, mixedconnective tissue disorder, multiple myeloma, cancer and cachexia,multiple organ disorder, myelo dysplastic syndrome, orchitismosteolysis, pancreatitis, including acute, chronic, and pancreaticabscess, polymyositis, progressive renal failure, pseudogout, pyodermagangrenosum, relapsing polychondritis, rheumatic heart disease,sarcoidosis, sclerosing cholangitis, stroke, thoracoabdominal aorticaneurysm repair (TAAA), TNF receptor associated periodic syndrome(TRAPS), symptoms related to Yellow Fever vaccination, inflammatorydiseases associated with the ear, chronic ear inflammation, chronicotitis media with or without cholesteatoma, pediatric ear inflammation,myotosis, ovarian cancer, colorectal cancer, therapy associated withinduced inflammatory syndrome (e.g., syndromes following IL-2administration), and a disorder associated with a reperfussion injury.

The methods of the invention also can be used to treat the followingdiseases: Acquired Immunodeficiency Disease Syndrome, AcquiredImmunodeficiency Related Diseases, acquired pernicious anaemia, acutecoronary syndromes, acute and chronic pain (different forms of pain),acute Idiopathic Polyneuritis, acute immune disease associated withorgan transplantation, acute or chronic immune disease associated withorgan transplantation, acute Inflammatory DemyelinatingPolyradiculoneuropathy, acute ischemia, acute liver disease, acuterheumatic fever, acute transverse myelitis, Addison's disease, adult(acute) respiratory distress syndrome, adult Still's Disease, alcoholiccirrhosis, alcohol-induced liver injury, allergic diseases, allergy,alopecia, Alopecia areata, Alzheimer's disease, Anaphylaxis, ankylosingspondylitis, ankylosing spondylitis associated lung disease,anti-Phospholipid Antibody Syndrome, aplastic anemia, Arteriosclerosis,arthropathy, asthma, atheromatous disease/arteriosclerosis,atherosclerosis, atopic allergy, Atopic eczema, Atopic dermatitis,atrophic autoimmune hypothyroidism, autoimmune bullous disease,Autoimmune dermatitis, autoimmune diabetes, Autoimmune disorderassociated with Streptococcus infection, Autoimmune Enteropathy,autoimmune haemolytic anaemia, autoimmune hepatitis, Autoimmune hearingloss, Autoimmune Lymphoproliferative Syndrome (ALPS), autoimmunemediated hypoglycaemia, autoimmune myocarditis, autoimmune neutropenia,autoimmune premature ovarian failure, autoimmune thrombocytopenia(AITP), autoimmune thyroid disease, autoimmune uveitis, bronchiolitisobliterans, Behcet's disease, Blepharitis, Bronchiectasis, Bullouspemphigoid, cachexia, Cardiovascular Disease, CatastrophicAntiphospholipid Syndrome, Celiac Disease, Cervical Spondylosis,Chlamydia, choleosatatis, chronic active hepatitis, chronic eosinophilicpneumonia, chronic fatigue syndrome, chronic immune disease associatedwith organ transplantation, Chronic ischemia, chronic liver diseases,chronic mucocutaneous candidiasis, Cicatricial pemphigoid, Clinicallyisolated Syndrome (CIS) with Risk for Multiple Sclerosis, common variedimmunodeficiency (common variable hypogammaglobulinaemia), connectivetissue disease associated interstitial lung disease, Conjunctivitis,Coombs positive haemolytic anaemia, Childhood Onset PsychiatricDisorder, Chronic obstructive pulmonary disease (COPD), Crohn's disease,cryptogenic autoimmune hepatitis, cryptogenic fibrosing alveolitis,Dacryocystitis, depression, dermatitis scleroderma, dermatomyositis,dermatomyositis/polymyositis associated lung disease, Diabeticretinopathy, Diabetes mellitus, dilated cardiomyopathy, discoid lupuserythematosus, disk herniation, disk prolaps, disseminated intravascularcoagulation, Drug-Induced hepatitis, drug-induced interstitial lungdisease, Drug induced immune hemolytic anemia, Endocarditis,Endometriosis, endophthalmitis, enteropathic synovitis, Episcleritis,Erythema multiforme, erythema multiforme major, female infertility,fibrosis, fibrotic lung disease, Gestational pemphigoid, giant cellarteritis (GCA), glomerulonephritides, goitrous autoimmunehypothyroidism (Hashimoto's disease), Goodpasture's syndrome, goutyarthritis, graft versus host disease (GVHD), Grave's disease, group Bstreptococci (GBS) infection, Guillain-Barre Syndrome (GBS),haemosiderosis associated lung disease, Hay Fever, heart failure,hemolytic anemia, Henoch-Schoenlein purpurea, Hepatitis B, Hepatitis C,Hughes Syndrome, Huntington's chorea, hyperthyroidism,hypoparathyroidism, idiopathic leucopaenia, idiopathic,thrombocytopaenia, Idiopathic Parkinson's Disease, idiopathicinterstitial pneumonia, idiosyncratic liver disease, IgE-mediatedAllergy, Immune hemolytic anemia, Inclusion Body Myositis, infectiousdiseases, Infectious ocular inflammatory disease, inflammatory boweldisease, Inflammatory demyelinating disease, Inflammatory heart disease,Inflammatory kidney disease, insulin dependent diabetes mellitus,interstitial pneumonitis, IPF/UIP, Iritis, juvenile chronic arthritis,juvenile pernicious anaemia, Juvenile rheumatoid arthritis, Kawasaki'sdisease, Keratitis, Keratojuntivitis sicca, Kussmaul disease orKussmaul-Meier Disease, Landry's Paralysis, Langerhan's CellHistiocytosis, linear IgA disease, Livedo reticularis, Lyme arthritis,lymphocytic infiltrative lung disease, Macular Degeneration, maleinfertility idiopathic or NOS, malignancies, microscopic vasculitis ofthe kidneys, Microscopic Polyangiitis, mixed connective tissue diseaseassociated lung disease, Morbus Bechterev, Motor Neuron Disorders,Mucous membrane pemphigoid, multiple sclerosis (all subtypes: primaryprogressive, secondary progressive, relapsing remitting etc.), MultipleOrgan failure, myalgic encephalitis/Royal Free disease, MyastheniaGravis, Myelodysplastic Syndrome, myocardial infarction, Myocarditis,nephrotic syndrome, Nerve Root Disorders, Neuropathy, Non-alcoholicSteatohepatitis, Non-A Non-B Hepatitis, optic neuritis, organ transplantrejection, osteoarthritis, Osteolysis, Ovarian cancer, ovarian failure,Pancreatitis, Parasitic diseases, Parkinson's disease, PauciarticularJRA, pemphigoid, pemphigus foliaceus, pemphigus vulgaris, peripheralartery occlusive disease (PAOD), peripheral vascular disease (PVD),peripheral artery disease (PAD), phacogenic uveitis, Phlebitis,Polyarteritis nodosa (or periarteritis nodosa), Polychondritis,Polymyalgia Rheumatica, Poliosis, Polyarticular JRA, PolyendocrineDeficiency Syndrome, Polymyositis, polyglandular deficiency type I andpolyglandular deficiency type II, polymyalgia rheumatica (PMR),postinfectious interstitial lung disease, post-inflammatory interstitiallung disease, Post-Pump Syndrome, premature ovarian failure, primarybiliary cirrhosis, primary myxoedema, primary parkinsonism, primarysclerosing cholangitis, primary sclerosing hepatitis, primaryvasculitis, prostate and rectal cancer and hematopoietic malignancies(leukemia and lymphoma), Prostatitis, psoriasis, psoriasis type 1,psoriasis type 2, psoriatic arthritis, psoriatic arthropathy, pulmonaryhypertension secondary to connective tissue disease, pulmonarymanifestation of polyarteritis nodosa, Pure red cell aplasia, PrimaryAdrenal Insufficiency, radiation fibrosis, reactive arthritis, Reiter'sdisease, Recurrent Neuromyelitis Optica, renal disease NOS, Restenosis,rheumatoid arthritis, rheumatoid arthritis associated interstitial lungdisease, Rheumatic heart disease, SAPHO (synovitis, acne, pustulosis,hyperostosis, and osteitis), sarcoidosis, Schizophrenia, Schmidt'ssyndrome, Scleroderma, Secondary Amyloidosis, Shock lung, Scleritis,Sciatica, Secondary Adrenal Insufficiency, sepsis syndrome, septicarthritis, septic shock, seronegative arthopathy, Silicone associatedconnective tissue disease, Sjogren's disease associated lung disease,Sjorgren's syndrome, Sneddon-Wilkinson Dermatosis, sperm autoimmunity,spondyloarthropathy, spondilitis ankylosans, Sporadic, Stevens-JohnsonSyndrome (SJS), Still's disease, stroke, sympathetic ophthalmia,Systemic inflammatory response syndrome, systemic lupus erythematosus,systemic lupus erythematosus associated lung disease, systemicsclerosis, systemic sclerosis associated interstitial lung disease,Takayasu's disease/arteritis, Temporal arteritis, Th2 Type and Th1 Typemediated diseases, thyroiditis, toxic shock syndrome, toxoplasmicretinitis, toxic epidermal necrolysis, Transverse myelitis, TRAPS (TumorNecrosis Factor Receptor, type B insulin resistance with acanthosisnigricans, Type 1 allergic reaction, type-1 autoimmune hepatitis(classical autoimmune or lupoid hepatitis), type-2 autoimmune hepatitis(anti-LKM antibody hepatitis), Type II Diabetes, ulcerative coliticarthropathy, ulcerative colitis, Urticaria, Usual interstitial pneumonia(UIP), uveitis, vasculitic diffuse lung disease, Vasculitis, Vernalconjunctivitis, viral retinitis, vitiligo, Vogt-Koyanagi-Harada syndrome(VKH syndrome), Wegener's granulomatosis, Wet macular degeneration,Wound healing, yersinia and salmonella associated arthropathy.

Other examples of disorders that can be used in the methods andcompositions of the invention are found in US Publication No.2004-0126372.

It is understood that all of the above-mentioned TNFα-related disordersinclude both the adult and juvenile forms of the disease whereappropriate. It is also understood that all of the above-mentioneddisorders include both chronic and acute forms of the disease. Inaddition, the multiple-variable dose methods of the invention can beused to treat each of the above-mentioned TNFα-related disorders aloneor in combination with one another, e.g., a patient who is sufferingfrom uveitis and lupus.

The invention also includes an article of manufacture comprising apackaging material; an automatic injection device, e.g., autoinjectorpen, containing a syringe filled with a TNFα inhibitor, such asadalimumab; and a label or package insert contained within the packagingmaterial indicating that in studies of the TNFα inhibitor using theautomatic injection device of the invention for the treatment ofrheumatoid arthritis, the most common adverse events (AEs) werebronchitis, hypersensitivity, arthritic pain, cough and rhinitis.

Other examples of biological agents which may be administered to a userusing the automatic injection device, e.g., autoinjector pen, of theinvention include, but are not limited to, antibodies to or antagonistsof human cytokines or growth factors, for example, TNF, LT, IL-1, IL-2,IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-15, IL-16, IL-18, IL-21, IL-23,interferons, EMAP-II, GM-CSF, FGF, and PDGF; antibodies to cell surfacemolecules such as CD2, CD3, CD4, CD8, CD25, CD28, CD30, CD40, CD45,CD69, CD80 (B7.1), CD86 (B7.2), CD90, CTLA or their ligands includingCD154 (gp39 or CD40L); Actemra (tocilizumab) humanized MAb againstinterleukin-6 (IL-6) receptor; TNFα converting enzyme (TACE) inhibitors;IL-1 inhibitors (Interleukin-1-converting enzyme inhibitors, IL-1RAetc.); Interleukin 11; IL-18 antagonists including IL-18 antibodies orsoluble IL-18 receptors, or IL-18 binding proteins; non-depletinganti-CD4 inhibitors; antagonists of the co-stimulatory pathway CD80(B7.1) or CD86 (B7.2) including antibodies, soluble receptors orantagonistic ligands; agents which interfere with signalling byproinflammatory cytokines such as TNFα or IL-1 (e.g. IRAK, NIK, IKK, p38or MAP kinase inhibitors); IL-1β converting enzyme (ICE) inhibitors;T-cell signalling inhibitors such as kinase inhibitors;metalloproteinase inhibitors; angiotensin converting enzyme inhibitors;soluble cytokine receptors and derivatives thereof (e.g. soluble p55 orp75 TNF receptors and the derivatives p75TNFRIgG (Enbrel™ and p55TNFRIgG(Lenercept)), sIL-1RI, sIL-1RII, sIL-6R); antiinflammatory cytokines(e.g. IL-4, IL-10, IL-11, IL-13 and TGFb); Rituximab; IL-1 TRAP; MRA;CTLA4-Ig; IL-18 BP; anti-IL-18; anti-IL15; IDEC-CE9.1/SB 210396(non-depleting primatized anti-CD4 antibody; IDEC/SmithKline; see e.g.,Arthritis & Rheumatism (1995) Vol. 38, S185); DAB 486-IL-2 and/or DAB389-IL-2 (IL-2 fusion proteins; Seragen; see e.g., Arthritis &Rheumatism (1993) Vol. 36, 1223); Anti-Tac (humanized anti-IL-2Ra;Protein Design Labs/Roche); IL-4 (anti-inflammatory cytokine;DNAX/Schering); IL-10 (SCH 52000; recombinant IL-10, anti-inflammatorycytokine; DNAX/Schering); IL-10 and/or IL-4 agonists (e.g., agonistantibodies); IL-1RA (IL-1 receptor antagonist; Synergen/Amgen); anakinra(Kineret®/Amgen); TNF-bp/s-TNF (soluble TNF binding protein; see e.g.,Arthritis & Rheumatism (1996) Vol. 39, No. 9 (supplement), 5284; Amer.J. Physiol.—Heart and Circulatory Physiology (1995) Vol. 268, pp.37-42); R973401 (phosphodiesterase Type IV inhibitor; see e.g.,Arthritis & Rheumatism (1996) Vol. 39, No. 9 (supplement), S282); MK-966(COX-2 Inhibitor; see e.g., Arthritis & Rheumatism (1996) Vol. 39, No. 9(supplement), S81); Iloprost (see e.g., Arthritis & Rheumatism (1996)Vol. 39, No. 9 (supplement), S82); zap-70 and/or lck inhibitor(inhibitor of the tyrosine kinase zap-70 or lck); VEGF inhibitor and/orVEGF-R inhibitor (inhibitors of vascular endothelial cell growth factoror vascular endothelial cell growth factor receptor; inhibitors ofangiogenesis); TNF-convertase inhibitors; anti-IL-12 antibodies;anti-IL-18 antibodies; interleukin-11 (see e.g., Arthritis & Rheumatism(1996) Vol. 39, No. 9 (supplement), S296); interleukin-13 (see e.g.,Arthritis & Rheumatism (1996) Vol. 39, No. 9 (supplement), S308);interleukin-17 inhibitors (see e.g., Arthritis & Rheumatism (1996) Vol.39, No. 9 (supplement), S120); anti-thymocyte globulin; anti-CD4antibodies; CD5-toxins; ICAM-1 antisense phosphorothioateoligo-deoxynucleotides (ISIS 2302; Isis Pharmaceuticals, Inc.); solublecomplement receptor 1 (TP10; T Cell Sciences, Inc.), efalizumab, andanti-IL2R antibodies, including anti-IL12 antibody (ABT 874); anti-IL18antibody (ABT 325); small molecule inhibitor of LCK; small moleculeinhibitor of COT; anti-IL1 antibody; small molecule inhibitor of MK2;anti-CD19 antibody; small molecule inhibitor of CXCR3; small moleculeinhibitor of CCR5; small molecule inhibitor of CCR11 anti-E/L selectinantibody; small molecule inhibitor of P2X7; small molecule inhibitor ofIRAK-4; small molecule agonist of glucocorticoid receptor; anti-C5areceptor antibody; small molecule inhibitor of C5a receptor; anti-CD32antibody; and CD32 as a therapeutic protein.

Other examples of biological agents which may be administered to a userusing the automatic injection device, e.g., autoinjector pen, of theapplication include, but are not limited to, small molecule inhibitor ofKDR (ABT-123), small molecule inhibitor of Tie-2; methotrexate;prednisone; celecoxib; folic acid; hydroxychloroquine sulfate;rofecoxib; etanercept; infliximab; anakinra (Kineret®/Amgen);leflunomide; naproxen; valdecoxib; sulfasalazine; ibuprofen;methylprednisolone; meloxicam; methylprednisolone acetate; gold sodiumthiomalate; aspirin; azathioprine; triamcinolone acetonide; propxyphenenapsylate/apap; folate; nabumetone; diclofenac; piroxicam; etodolac;diclofenac sodium; oxaprozin; oxycodone hcl; hydrocodonebitartrate/apap; diclofenac sodium/misoprostol; fentanyl; anakinra,human recombinant; tramadol hcl; salsalate; sulindac;cyanocobalamin/fa/pyridoxine; acetaminophen; alendronate sodium;prednisolone; morphine sulfate; lidocaine hydrochloride; indomethacin;glucosamine sulfate/chondroitin; cyclosporine; sulfadiazine;amitriptyline hcl; oxycodone hcl/acetaminophen; olopatadine hcl;misoprostol; naproxen sodium; omeprazole; mycophenolate mofetil;cyclophosphamide; rituximab; IL-1 TRAP; MRA; CTLA4-IG; IL-18 BP;ABT-874; ABT-325 (anti-IL 18); anti-IL 15; BIRB-796; SCIO-469; VX-702;AMG-548; VX-740; Roflumilast; IC-485; CDC-801; and mesopram,antibiotics, including clarithromycin (Biaxin®), ciprofloxacin (Cipro®),and metronidazole (Flagyl®), mesalamine, prednisone, azathioprine,mercaptopurine, infliximab, budesonide, sulfasalazine,methylprednisolone sod succ, diphenoxylate/atrop sulf, loperamidehydrochloride, methotrexate, omeprazole, folate, ciprofloxacin/dextrose-water, hydrocodone bitartrate/apap, tetracycline hydrochloride,fluocinonide, metronidazole, thimerosal/boric acid, hyoscyamine sulfate,cholestyramine/sucrose, ciprofloxacin hydrochloride, meperidinehydrochloride, midazolam hydrochloride, oxycodone hcl/acetaminophen,promethazine hydrochloride, sodium phosphate,sulfamethoxazole/trimethoprim, celecoxib, polycarbophil, propoxyphenenapsylate, hydrocortisone, multivitamins, balsalazide disodium, codeinephosphate/apap, colesevelam hcl, cyanocobalamin, folic acid,levofloxacin, natalizumab, methylprednisolone, interferon-gamma,sargramostim (GM-CSF), nonsteroidal, anti-inflammatory drugs (NSAIDs),COX 2 inhibitors, including Celebrex®, Vioxx®, and Bextra®, etoricoxib,ibuprofen, diclofenac and misoprostol, naproxen, meloxicam,indomethacin, diclofenac, celecoxib, rofecoxib, sulfasalazine,prednisone, methotrexate, azathioprine, minocyclin, prednisone,etanercept, and infliximab; rofecoxib; celecoxib; folic acid;sulfasalazine; naproxen; leflunomide; methylprednisolone acetate;indomethacin; hydroxychloroquine sulfate; sulindac; prednisone;betamethasone diprop augmented; infliximab; methotrexate; folate;triamcinolone acetonide; diclofenac; dimethylsulfoxide; piroxicam;diclofenac sodium; ketoprofen; meloxicam; prednisone;methylprednisolone; nabumetone; tolmetin sodium; calcipotriene;cyclosporine; diclofenac; sodium/misoprostol; fluocinonide; glucos aminesulfate; gold sodium thiomalate; hydrocodone; bitartrate/apap;ibuprofen; risedronate sodium; sulfadiazine; thioguanine; valdecoxib;alefacept; RAPTIVA® (efalizumab), small molecule inhibitor of KDR(ABT-123), small molecule inhibitor of Tie-2, calcipotriene, clobetasolpropionate, triamcinolone acetonide, halobetasol propionate, tazarotene,methotrexate, fluocinonide, betamethasone diprop augmented,fluocinolone, acetonide, acitretin, tar shampoo, betamethasone valerate,mometasone furoate, ketoconazole, pramoxine/fluocinolone, hydrocortisonevalerate, flurandrenolide, urea, betamethasone, clobetasolpropionate/emoll, fluticasone propionate, azithromycin, hydrocortisone,moisturizing formula, folic acid, desonide, coal tar, diflorasonediacetate, etanercept, folate, lactic acid, methoxsalen, hc/bismuthsubgal/znox/resor, methylprednisolone acetate, prednisone, sunscreen,salicylic acid, halcinonide, anthralin, clocortolone pivalate, coalextract, coal tar/salicylic acid, coal tar/salicylic acid/sulfur,desoximetasone, diazepam, emollient, pimecrolimus emollient,fluocinonide/emollient, mineral oil/castor oil/na lact, mineraloil/peanut oil, petroleum/isopropyl myristate, psoralen, salicylic acid,soap/tribromsalan, thimerosal/boric acid, celecoxib, alefacept, RAPTIVA®(efalizumab), tacrolimus, pimecrolimus, PUVA, and sulfasalazine.

This invention is further illustrated by the following examples, whichshould not be construed as limiting. The contents of all references,patents and published patent applications cited throughout thisapplication are incorporated herein by reference.

The following examples describe studies using an exemplary automaticinjection device, e.g., autoinjector or autoinjection pen, of theinvention. The exemplary autoinjector pen described in the followingexamples contains a human TNFα antibody, e.g., adalimumab (HUMIRA®) andis often referred to as the “HUMIRA® pen” below.

EXAMPLE 1 Use of Automatic Injection Device for Administering TNFαInhibitor Overview/Summary of Study

Adalimumab is a therapeutic monoclonal antibody for subcutaneousadministration by 2 bioequivalent, single-use injection devices: aready-to-use, prefilled syringe and an integrated, disposable deliverysystem, the autoinjection pen. Although pens have been shown to bepreferred over syringes by patients requiring long-term subcutaneousadministration of medications, there are no data on preference and painin the use of biologics in patients with chronic inflammatory diseases.Thus, the objective of the following study (the TOUCH study) was toassess injection-site pain, safety, and patient preference of 2 deliverysystems of adalimumab.

The objective of the TOUCH study (Trial Of Usability in Clinicalsettings of HUMIRA Autoinjector vs. Prefilled Syringe) was to assesswhich method of delivery rheumatoid arthritis patients preferred: theHUMIRA prefilled syringe that they were already using, or the new HUMIRAPen.

Briefly, patients with rheumatoid arthritis (RA) were enrolled in aPhase II, multicenter, open-label, single-arm, sequential trial.Patients self-administered a standard dose of adalimumab subcutaneouslyevery other week at each of 3 monitored clinical visits: Visit 1(syringe), Visits 2 and 3 (pen). At each visit, patients rated theirpain at 2 time points and provided their impressions of and preferencesfor each delivery system. Safety was evaluated throughout the study and70 days after final study dose.

Overall, fifty-two patients were enrolled in the trial and completed all3 visits. Forty patients (76.9%) reported that the pen was less painfulthan the syringe, 4 patients (7.7%) found the syringe to be lesspainful, and 8 patients (15.4%) had no preference. At Visits 2 and 3,patients had significant mean reductions in injection site painimmediately post-injection (−1.4 and −1.6, respectively, p<0.01) and15-30 minutes post-injection (−0.6 at both time points, p<0.01). ˜90% ofpatients found the pen more convenient and easier to use. Patients hadstatistically significant reductions in injection-pain scores from Visit1 to Visit 2 and from Visit 1 to Visit 3. The types and cumulativefrequency of AEs during the 2-wk period after the syringe injection andthe 4-wk period after the 2 pen injections were comparable. Fivepatients (9.6%) reported AEs, including bronchitis, hypersensitivity,arthritic pain, cough and rhinitis after syringe injection and 8 (15.4%)after pen injection. There were no AEs leading to discontinuation. Thus,both delivery systems were safe, and no significant differences inadverse events were reported for either delivery system. In addition, 46patients (88.5%) preferred the pen, 3 (5.8%) preferred the syringe, and3 (5.8%) had no preference. Overall, patients evaluated the pen aseasier to use, more convenient, requiring less time to inject, andsafer.

In conclusion, patients experienced less pain self-administeringadalimumab via the pen and preferred it over, the syringe. Further,patients perceived the pen to be easier to use and more convenient. Nodifferences in safety events were reported between the 2 bioequivalentdelivery systems.

Detailed Study

The following study was performed to assess which method of deliverypatients (also referred to herein as users) preferred—either the HUMIRA®(also referred to as adalimumab) prefilled syringe (PFS) or the newHUMIRA® pen. The following study was also performed to compare the twomodes of administration, including the level of injection-site pain ofthe 2 delivery systems.

The study design included a phase II, multicenter, open-label study,that included patients who had prior experience administering adalimumabusing the prefilled syringe. Patients who were ≧18 years of age, had RAdiagnosed according to the 1987 revised American College of Rheumatologycriteria, and had been self-administering adalimumab 40 mgsubcutaneously every other week via the prefilled syringe for at least 3months were eligible to enroll. Major exclusion criteria includedpatients with a history of malignancy; patients who wereimmunocompromised or had a history of human immunodeficiency virus,demyelinating diseases, or poorly controlled chronic disease; patientswith active infections requiring treatment; patients with activetuberculosis or a positive purified protein derivative test within thelast 6 months; patients who received live investigational drugs within30 days or 5 half-lives; patients who were regularly using anymedication administered via subcutaneous injection except foradalimumab; and women who were pregnant or breastfeeding. Patients inthis study were allowed to continue prestudy dosages of standardantirheumatic drug therapies.

Patients (n=52) self-injected with the HUMIRA® prefilled syringe at week0 followed by injections of the HUMIRA® pen at weeks 2 and 4, completingquestionnaires at all 3 time points. Patients rated their injectionpreference for several attributes, including overall preference, ease ofuse, convenience, time to complete injection, perceived safety, andpain. The study included 3 study visits for patient self-administrationof adalimumab every other week. Each injection was administered underthe supervision of a health care professional at each visit. At Visit 1,patients self-administered adalimumab 40 mg subcutaneously via aprefilled syringe held at a 45-degree angle to the skin. At Visit 2,patients were instructed by study personnel on proper administration ofadalimumab via the pen and on the pen's features (FIG. 25), includingthe window for viewing the drug solution before injection and a yellowband to indicate complete injection; the sequential opening of safetycaps to prevent accidental misfiring; and the proper positioning, grasp,and one-touch activation of the device. At Visits 2 and 3, patientsself-administered adalimumab via the pen held at a 90-degree angle tothe skin. Patients chose to self-inject in either the thigh or abdomenat Visit 1 and were monitored to ensure they used the same body locationfor injection at Visits 2 and 3, keeping each injection at least 2inches from the previous injection site.

The pen was used by the patient according to the following protocol:patients were first familiarized with the pen by watching aninstructional video and reading a 5-step brochure prior to the peninjection. Patients also used a demonstration pen to practice using thedevice prior to the pen injection. The steps for using the HUMIRA® penincluded setting up the pen, wherein the pen was removed from the boxand allowed to acclimate to room temperature by letting it sit for 15-20minutes. The patient then swabs themselves with an alcohol swab prior toinjection. The injection site was chosen and prepared. HUMIRA® wasinjected using the pen, such that the patient pressed the activationbutton. Once the “click” was heard, the injection began and lasted about10 seconds. After 10 seconds or when the yellow stopped moving in thewindow, the injection was complete.

Baseline demographics for the study included patients who had been usingthe HUMIRA® PFS between 3-32 months, with a mean of 15.4 months.Patients reported that self-injection with PFS too <1 minute to 5minutes, with an average of <1 minute. Baseline assessments includedduration of adalimumab treatment, duration of self-administration ofadalimumab, usual site of injection, length of time to inject, andoverall impression of adalimumab administration via a syringe.Injection-site pain was rated on an 11-point numeric rating scaleranging from 0 (no pain) to 10 (pain as bad as it could be) at 2 timepoints post-injection: immediately post-injection and 15-30 minutespost-injection (Huskisson Lancet. 1974; 304:1127-1131 and Jorgensen etal. Annals of Pharmacotherapy. 1996; 30:729-732). Following eachinjection, patients also rated their overall impressions of the syringevs. the pen as “extremely unfavorable,” “unfavorable,” “neutral,”“favorable,” or “extremely favorable.”

At week 0, patients were asked the following information: the amount oftime they have been on HUMIRA®, their typical injection site, theirtypical time of injection, and their overall impression of the syringe.The most common injection sites were the abdomen (25/52) and the thigh(22/52).

A patient preference survey was administered following the last visit orupon early termination from the study. The survey asked patients to ratetheir overall preferences (syringe, pen, or no preference) and therationales for their preferences. Patient preference (syringe, pen, orno preference) was also rated for each of the following categories: easeof use, convenience, time to administer injection, safety, and lesspain. Patients were also asked to rate their likelihood of switching tothe pen if available at the same price (“extremely unlikely,”“unlikely,” “neutral,” “likely,” or “extremely likely”), and theirlikelihood of recommending the pen to another patient receivingadalimumab (same ratings as above). At the first and third injections(weeks 2 and 4), patients were asked to rate the immediate pain usingthe pen (scale of 0-10, wherein 0=no pain and 10=pain as bad as it couldbe), the amount of pain at 15-30 minutes (0-10 scale), their overallimpression, their injection site, whether they experienced a wet ornormal injection, their adherence to the instructions of the pen, andany additional comments.

At the end of the study, patients were given a final preferencequestionnaire to determine the following attributes: overall preference,as well as reasons; specific preference, relating to ease of use,convenience, time of injection, safety, less pain; whether the patientwould be likely to switch from the PFD to the pen; and whether thepatient would be likely to recommend the pen to other patients usingadalimumab.

Safety was assessed at baseline (for reference) and throughout the studyusing clinical laboratory data and physical examination findings.Patients were monitored for treatment-emergent adverse event (AE)reports, whether reported spontaneously by the patient or by theinvestigator. A serious AE was defined according to the MedicalDictionary for Regulatory Activities (MedDRA version 9.0) as an AE thatwas fatal or life-threatening; required prolonged inpatienthospitalization; resulted in persistent or significant disability,congenital anomaly, birth defect, miscarriage, or elective abortion; orrequired medical/surgical intervention to prevent another seriousoutcome. Number and percentage of study patients with AEs were reportedfrom signed informed consent up to 70 days after last study visit (5times the estimated half-life of adalimumab). Assessments of drug safetyand tolerability also compared the 2- and 4-week periods afteradministration of the syringe and pen, respectively. Routine hematology,serum chemistry and serology, and urinalysis tests were conductedthrough a certified clinical laboratory. Laboratory reference rangeswere obtained prior to the initiation of the study and reviewed by theinvestigator for screening purposes.

A sample size of approximately 50 patients was needed to demonstrateequivalence between the injection-site pain scores followingadministration of the prefilled syringe vs. the pen with 80% statisticalpower, assuming an equivalence limit of ±5, a standard deviation (of thedifferences) of 1.25, and a 1-sided, Type-I error rate of 0.025.Evaluations of preference and injection-site pain covered allparticipants who received 1 injection with a syringe and at least 1injection with the pen. Baseline characteristics, preferences, and othercategorical data were summarized using means and percentages. An “exact”95% CI was computed to compare the patients who either preferred the penor had no preference with patients who preferred the prefilled syringe.Changes from baseline in injection-site pain were analyzed using pairedstudent t-test and calculation of 95% CIs. Safety analyses covered allpatients who received at least 1 injection. AE rates using each devicewere compared using the McNemar's test. All statistical tests wereperformed at the 0.05-level of statistical significance. The statisticalanalysis was performed using SAS®, Release 8.2 (SAS Institute, Inc,Cary, N.C.) with a UNIX Version 11.0 operating system.

Interim Study Results

Interim Study 1

An interim study examined statistical and descriptive analysis ofinformation obtained from 17 patients, 11 had all 3 visits and 6 had 2visits. The study also examined baseline and visit 1 data from another 7patients.

Overall excellent results suggested that the pen is preferred over thesyringe. Injection pain was comparable with either the pen or syringe,while post injection site pain showed differences, mostly in favor ofthe pen:

-   Most patients reported either no or minimal pain during injection    with both devices.-   The majority reported less post-injection site pain with the pen    than the syringe (Mean values in a 0-10 scale: 3.6 (syringe); 2.4    (pen 1); 1.9 (pen 2)).

Preference: Practically all patients found superior the pen for allrating attributes such as overall preference, less pain, ease of use,convenience or safety. The pen was preferred in 63 out of 66 answers (6preference questions to 11 patients).

All 11 patients considered likely (4) or extremely likely (7) switchingto and recommending the pen to others.

Additional details of interim study 1, included the following:

Pain data: (17 patients pen 1; 11 patients pen 2) is shown below inTable 1.1, where injection pain (scale 0-10; mean values)—pen ‘always’either same or lower pain than syringe

TABLE 1.1 Injection pain (scale 0-10; mean values) - pen ‘always’ eithersame or lower pain than syringe Syringe 0.8 pen 1 0.2 pen 2 0.1Table 1.2 below shows details of study 1 based on a different patientpopulation described in Table 1.1 Post-injection site pain (scale 0-10;mean values)—11 patients reported similar or less pain with the pen, in6 patients the pen increased pain from 1 to 3-5

Injection pain (scale 0-10; mean values) Syringe 3.6 pen 1 2.4 pen 2 1.9

Preference Data (EF: Extremely Fav; F Fav; N: Neutral; U: Unfav; EU:Extremely Unfav)

Pen 1: overall impression was mostly EF (7) or F (6).

Pen 2: was mostly EF (6) or F (4). Patient 904 had EU in pen 2, althoughhad EF in pen 1, but also had an ‘extremely likely’ to switch andrecommend.

Interim Study 2

An interim study (following interim study 1 in time) examined 19patients with 3 injections. The interim study 1 summary includedexclusively preference results based on descriptive analyses obtainedfrom 31 patients: 19 had all 3 visits, 5 had 2 visits and 7 had just thefirst visit.

Overall excellent results confirming that the pen is definitelypreferred over the syringe. Practically all patients found superior thepen for all rating attributes such as overall preference, less pain,ease of use, convenience or safety. The pen was preferred in 106 out of114 answers (6 preference questions to 19 patients).

18 out of 19 patients preferred the pen and considered extremely likelyor likely switching to and recommending the pen to others. One patientpreferred the syringe, considered unlikely to switch and was neutralregarding recommendation. Additional details included the following:

Subject Impression of Syringe:

n=31

Extremely favorable=2 (6.5%)

Favorable=8 (26%)

Neutral=11 (35%)

Unfavorable=8 (26%)

Extremely Unfavorable=2 (6.5%)

Subject Impression After Visit 2—1st Pen Injection

n=24

Extremely Favorable=12 (50%)

Favorable=8 (33.3%)

Neutral=2 (8.3%)

Unfavorable=1 (4.2%)

Extremely Unfavorable=1 (4.2%)

Subject Impression After Visit 3—2nd Pen Injection

n=19

Extremely Favorable=11 (57.9%)

Favorable=6 (31.6%)

Neutral=1 (5.3%)

Extremely Unfavorable=1 (5.3%)

Preference Ratings After Visit 3—2nd Pen Injection

n=19

When asked overall, based on your experience with the HUMIRA® Syringeand the pen which do you prefer? 18 of 19 subjects preferred the pen.One subject preferred the Syringe.

When asked which method of injecting HUMIRA® was preferred in terms of:

Ease of Use—All 19 subjects preferred the pen

Convenience—18 subject preferred the pen; 1 subject reported NoPreference

Time it took to complete the Injection—17 of 19 subject preferred thepen; 2 subjects had No Preference

Safety—17 of 19 subject preferred the pen; 2 subjects had No Preference

Less Pain—16 of 19 subject preferred the pen; 1 subject preferred theSyringe; and 2 subjects has No Preference

When asked “How likely would you be to use the pen if it was availableat the same cost as the Syringe?” 12 subjects reported “ExtremelyLikely”; 6 subjects reported “Likely”; and 1 subject reported “Unlikely”

When asked “How likely would you be to recommend the pen to anotherHUMIRA® user?” 11 users reported “Extremely Likely”; 7 users reported“Likely”; and 1 user reported “Neutral.”

Some comments reported by users who selected their preference as thepen:

“Easy, and less pain, quicker”

“Safer, faster & easier to administer no fear factor”

“Because I don't like needle I can actually see”

“Easier to hold/administer”

“Less painful quick and easy”

“It does it all for you”

“It takes the hassle of having to tab myself+control the injection outof the process. And id didn't seem to hurt as much.”

“There is not as much pain”

“Convenience”

“Pain is less severe and lasts a shorter period”

Some Comments Reported by Users as to why they did NOT Select theSyringe as their Preference:

“Hurts”

“More prep time, physical and mental”

“The syringe takes longer, more steps.”

“Harder to use”

“Slower more pain”

“Harder to hold/administer”

“Could feel the sting when it goes in, more painful”

“With the syringe you have to push down until done vs. pen push downonce and watch yellow tab till it stops”

“To me, the pen is easier, with less chance of error on my part”

“Because the pen is easier to use and not as much pain after:

“Slower injection time—more painful”

“Slow process—stings”

Info from the Subject who Preferred the Syringe:

Ease of use—preferred the pen; Convenience—preferred pen; Time it tookto complete injection—pen; Safety—pen; Less Pain—Syringe; How likely touse pen—Unlikely; How likely to recommend pen—Neutral

Comments—“I seem to be in better control of the injection needle. Thesecond injection felt more painful than the syringe.”

Interim Study 3

In interim study 3, the following answers were given in a survey of 35patients:

-   -   Which method of injecting HUMIRA® would you prefer in terms of        the time it took to complete the injection? pen (n=29); Syringe        (n=2); no preference (n=4)    -   Which method of injecting HUMIRA® would you prefer in terms of        safety? pen (n=31); syringe (n=0); no preference (n=4)        Results from Complete Study

Patient Disposition and Baseline Characteristics

A total of 52 patients were enrolled in the study and completed all 3study visits. No patients discontinued treatment during the study.Baseline demographics and baseline survey results are included in Table1.3. Patients enrolled in the study were treated with adalimumab for amean treatment duration of 15.4 months and were self-administeringadalimumab with a syringe for the majority of their treatment periods(mean duration of self-administration was 14.9 months). In addition,approximately 655 of patients were receiving concomitant methotrexate,and 35% were receiving concomitant steroid therapy. Patients were fairlyequally divided as to whether they usually injected their adalimumabdoses in the abdomen or thigh, whereas a small percentage alternatedbetween sites. During the study, 29 patients (55.8%) selected theirabdomens as their injection site, and 23 patients (44.2%) selected theirthighs as their injection site.

TABLE 1.3 Baseline Demographics, Clinical Characteristics, and SurveyResponses Overall Characteristic Population (N = 52) Mean age in years(SD) 53.8 (12.1)  Mean disease duration of rheumatoid arthritis (SD) 8(7.5) Gender, n (%) Female 32 (61.5) Male 20 (38.5) Race, n (%) White 46(88.5) Black  6 (11.5) Other 0 (0)  RA medications in past 12 months, n(%) Adalimumab 52 (100)  Etanercept 2 (3.8) Infliximab 2 (3.8) Other 1(1.9) Baseline Survey N = 52 Duration of adalimumab treatment (mos) Mean(SD) 15.4 (9.8)   Median 12.0 Range 3.0-40.0 Duration of self-injectingadalimumab (mos) Mean (SD) 14.9 (10.0)  Median 12.0 Range 2.0-40.0Length of time to inject (min) Mean (SD) 1.6 (4.1)  Median  0.8 Range0.2-30.1 Usual injection site, n (%) Abdomen 25 (48.1) Thigh 22 (42.3)Both abdomen and thigh 5 (9.6) RA = rheumatoid arthritis.

Injection-Site Pain

Injection-site pain ratings are included in Table 2. At Visit 1,immediately following the syringe injection, the mean injection-sitepain rating was 3.7. Mean pain ratings decreased 37% to 2.3 at Visit 2and 46% to 2.0 at Visit 3, immediately following the pen injection. Meanwithin group changes in injection-site pain immediately following theinjection at Visit 2 (pen) and Visit 3 (pen) were statisticallysignificantly reduced (P=0.002 and P<0.001, respectively) from Visit 1(syringe) (Table 2). Mean pain rating 15-30 minutes post-injection were0.8 at Visit 1; 0.2 at Visit 2; and 0.2 at Visit 3. Similarly, meanwithin group changes in injection-site pain 15-30 minutes post-injectionat Visit 2 (pen) and Visit 3 (pen) were statistically significantlyreduced (P=0.004 and P=0.001, respectively) from Visit 1 (syringe)(Table 2).

TABLE 2 Injection-Site Pain Full Analysis Set N = 52 Within-Group ChangeVisit from Week 1 P- Visit Mean Mean ± SE 95% CI value Immediatelypost-injection Visit 1 (Week 1) (Syringe) 3.7 Visit 2 (Week 3) (pen) 2.3−1.4 ± 0.43 −2.2, −0.5 0.002 Visit 3 (Week 5) (pen) 2.0 −1.6 ± 0.44−2.5, −0.8 <0.001 15-30 minutes post-injection Visit 1 (Week 1)(Syringe) 0.8 Visit 2 (Week 3) (pen) 0.2 −0.6 ± 0.19 −1.0, −0.2 0.004Visit 3 (Week 5) (pen) 0.2 −0.6 ± 0.16 −0.9, −0.2 0.001 Note: Thepossible range for the assessment of pain is 0 (no pain) to 10 (pain asbad as it could be).

Overall Impressions

At Visit 1, patients were equally divided in rating their overallimpressions of their first syringe injections. Approximately one-thirdof the patients rated their overall impressions of the syringe injectionas “favorable” or “extremely favorable,” approximately one-third were“neutral,” and approximately one-third rated it as “unfavorable” or“extremely unfavorable” (Table 3). Following the use of the pen, morethan 80% of the patients rated their overall impressions of the pen as“favorable” or “extremely favorable” at Visit 2 (86.5%) and Visit 3(88.5%).

TABLE 3 Overall Impressions of Adalimumab Prefilled Syringe andAutoinjection pen Syringe, n (%) pen, n (%) Visit 1 Visit 2 Visit 3Response N = 52 N = 52 N = 52 Extremely favorable 2 (3.8) 26 (50.0) 33(63.5) Favorable 15 (28.8) 19 (36.5) 13 (25.0) Neutral 18 (34.6) 3 (5.8)3 (5.8) Unfavorable 14 (26.9) 1 (1.9) 2 (3.8) Extremely unfavorable 3(5.8) 3 (5.8) 1 (1.9)

Patient Preference

The final patient preference survey that was administered followingVisit 3 showed that, overall, 88.5% (95% CI 84.1, 98.8) of patientspreferred the pen, 5.8% (95% CI 1.2, 15.9) preferred the syringe, and5.8% had no preference (FIG. 26). Patients were asked to list some ofthe reasons for their preferences. The majority of patients who chosethe pen as their preferred delivery system said it was easier to use andless painful than the syringe. Other reasons why patients preferred thepen included the following: no bruising at injection site; fasteradministration time; less preparation time and fewer steps to follow;better control of the device; less force required; no need to pushsyringe to insert needle into skin; no view of the needle; fewerconcerns with needle storage and disposal; and no need to draw back onsyringe to check for blood. Patients who chose the syringe as theirpreferred delivery system gave the following reasons: familiarity withthe syringe/no need for change; difficulty removing pen cap; bettercontrol of the injection needle; and less painful than the pen.

When patients were asked to rate specific reasons for their preferences,more preferred the pen over the syringe for (in order from greatest tolowest percentage) the following: ease of use; convenience; overallsafety and overall attributes (same percentage); less time to completethe injection, and less pain (FIG. 2). More than 94% of patients saidthey would be likely or extremely likely to use the pen if it wasavailable at the same cost as the syringe (FIG. 27). Similarly, morethan 94% of patients said they would recommend the pen to anotherpatient who uses adalimumab (FIG. 27).

Therapy Compliance

At each visit, patients had their injection techniques assessed by ahealth care professional to help determine the effectiveness of thetraining procedure. Overall, patient preparation and injectiontechniques were rated at 98-100% compliant (per visit) for eachcomponent assessed (ie, prepared the injection site with alcohol,inspected the drug level and quality, removed the caps in order,prepared the skin plateau, kept the skin plateau during the injection,positioned the pen correctly, fired the pen correctly, kept constantpressure with no pull back, held the injection until complete, andobserved the yellow stopper in the window when the injection wascomplete). Approximately 90% of patients noted that the instructionaldevices (video or brochures) used by the health care professionalsprovided adequate training.

Safety Assessments

No new safety signals were observed during this study. Adalimumab wasdemonstrated to be generally safe and well-tolerated irrespective ofsyringe or pen delivery. No statistically significant differences wereobserved between AEs reported during syringe use vs. pen use either interms of overall AEs or by individual MedDRA preferred term. A total of13 patients reported a treatment-emergent AE: 5 while using theprefilled syringe (9.6%) and 10 (19.2%) after 2 pen injections. Twopatients reported an AE during both syringe and pen use. Most AEs weremild to moderate and included bronchitis, hypersensitivity, arthriticpain, cough, and rhinitis. Three infections and 1 drug hypersensitivityreaction were reported. Two patients had a serious AE while using thepen. Of these, a 69-year-old white male with a history of hypertensionand coronary artery disease leading to triple bypass cardiac surgeryrequired hospitalization because of exacerbation of congestive heartfailure, a diagnosis first established in 1989. This patient receivedthe second dose of adalimumab via pen once stabilized and recovered. Theother patient was a 51-year-old white male who required hospitalizationfor the treatment of pneumonia approximately 71 days after the start ofstudy treatment. No other TNF-antagonist events of interest, includingmalignancies, demyelinating events (including multiple sclerosis), orlupus-like reactions, were reported during this study. No patientsdiscontinued from the study in response to a treatment-emergent AE, andno device failures were reported.

The final results of the study show that 46 out of 52 patients preferredthe pen (88.5%), while 5.8% (n=3) had no preference and 5.8% preferredthe PFS (n=3). In addition, 40 out of 52 patients thought the pen wasless painful (76.9%), while 15.4% had no preference. Only 7.7% thoughtthe PFS was less painful. Furthermore, patient responses indicated thatthe pen was easier to use, as 49 of 52 patients thought the pen waseasier to use (94.2%). Finally, the pen was deemed more convenient, as48 of 52 patients thought the pen was more convenient (92.3%). 61.5%(n=32) of the patients said that they would be likely to recommend thepen to another HUMIRA® user, while 32.7% (n=17) said they would belikely to recommend and 5.8% (n=3) were neutral on the issue. Additionalresults from the study are shown below in Tables 4-6.

TABLE 4 Results from questionnaire regarding “How painful was theHUMIRA ® injection you just administered?” (both immediately and 15-30minutes) WEEK 1 (SYRINGE) VISIT VISIT N MEAN MEAN IMMEDIATELY POSTINJECTION WEEK 3 (PEN) 52 3.7 2.3^(@) WEEK 5 (PEN) 52 3.7 2.0* 15-30 MINPOST INJECTION WEEK 3 (PEN) 52 0.8 0.2^(&) WEEK 5 (PEN) 52 0.8 0.2^(#)*P-value <0.001 ^(#)P-value 0.001 ^(@)P-value 0.002 ^(&)P-value 0.004

TABLE 5 Subject impression: overall impression WEEK 1 WEEK 3 WEEK 5(SYRINGE) (PEN) (PEN) (N = 52) (N = 52) (N = 52) IMPRESSION n (%) n (%)n (%) EXTREMELY UNFAVORABLE 3 (5.8) 3 (5.8) 1 (1.9) UNFAVORABLE 14(26.9) 1 (1.9) 2 (3.8) NEUTRAL 18 (34.6) 3 (5.8) 3 (5.8) FAVORABLE 15(28.8) 19 (36.5) 13 (25.0) EXTREMELY FAVORABLE 2 (3.8) 26 (50.0) 33(63.5)

TABLE 6 Method preferred in different cases Time it took to completeEase the Total of use Convenience injection Safety Less pain n = 52 n(%) n (%) n (%) n (%) n (%) pen 49 (94.2) 48 (92.3) 43 (82.7) 46 (88.5)40 (76.9) Syringe 2 (3.8) 1 (1.9) 3 (5.8) 0 4 (7.7) No 1 (1.9) 3 (5.8) 6 (11.5)  6 (11.5)  8 (15.4) preference

The types and cumulative frequency of adverse events (AEs) during the2-wk period after the syringe injection and the 4-wk period after the 2pen injections were comparable. Five patients (9.6%) reported AEs,including bronchitis, hypersensitivity, arthritic pain, cough andrhinitis after syringe injection and 8 (15.4%) after pen injection.There were no AEs leading to discontinuation.

Although the pen was designed to offer patients greater convenience, itwas unclear what attributes, such as less pain, would drive patients'preferences. This study showed that individual attributes—less injectionpain, safety, ease of use, convenience, and time to complete theinjection—all favored the pen over the syringe. In this study, the penshowed a statistically significant advantage regarding injection pain,which was reduced by 46% immediately after injection, and by 75% 15-30minutes post-injection.

Regarding preference, patients were equally divided on their overallimpressions of the syringe with respect to 5 prespecified categories(ie, “extremely favorable,” “favorable,” “neutral,” “unfavorable,” and“extremely unfavorable”). However, after switching to the pen, patients'overall impression ratings shifted significantly toward either“favorable” or “extremely favorable.” Moreover, after only 2 injectionswith the pen, the majority of patients said they were “likely” or“extremely likely” to switch to the pen and to recommend the pen toanother patient who was being treated with adalimumab, highlightingpatients' quick acceptance of the pen and its features.

These results may have important treatment implications for patients whorequire long-term TNF inhibitor or other biologic therapies. Because ofthe relationship of patient preference to adherence to therapy(Schwartzman et al. Arthritis Research & Therapy. 2004; 6(Suppl2):S19-S23), a patient's preference for a specific route ofadministration may be a substantial factor in a physician's selection ofa biologic therapy. Moreover, adherence to therapy is believed to be oneof the most important factors in maintaining the long-term benefits ofTNF-antagonist therapy, and, therefore, the lack of adherence canseverely compromise the effectiveness of treatment (Schwartzman et al.(2004)).

In sum, the pen was determined by patients to be easier to use than aprefilled syringe. In addition, patients found that the pen was moreconvenient than the syringe and was less painful than the prefilledsyringe. Patients preferred the HUMIRA® pen to the HUMIRA® PFS acrossall rating attributes. About 90% of the patients reported an overallpreference for the pen compared to the prefilled syringe. 8 out of 10patients also would recommend the pen to other patients usingadalimumab. Finally, 80% of the patients rated the pen as less painfulthan the PFS.

This study indicates that patients believed that the adalimumab pencaused significantly less pain than the traditional prefilled syringe.In additions, adalimumab-experienced RA patients preferred subcutaneousinjection of adalimumab with an autoinjection pen over injection withthe prefilled syringe. Patients thought the pen was easier to use, moreconvenient, safer, and required less time to inject. With regard to thesafety profile, no apparent differences were observed between the 2delivery systems. The overall preference of patients for anautoinjection pen device may lead to increased adherence to therapy and,in turn, improved clinical outcomes during long-term therapy withself-administered biologic therapies.

EXAMPLE 2 Assessment of Relative Bioavailability, Safety, andTolerability of Single Doses of Adalimumab Administered Via anAutoinjector Pen and a Prefilled Syringe

Rheumatoid arthritis (RA) is a chronic, debilitating disease thatrequires long-term therapy that is safe and efficacious. Current toolsof biologic drug delivery, prefilled syringes, are painful andcumbersome. Prefilled, disposable, autoinjector pens, like thosedescribed in the below example, allow for more convenient dosing.

The purpose of the following example was to compare the bioavailability,safety, and tolerability of adalimumab administered subcutaneously viaan autoinjector pen vs. a prefilled syringe

Study Design

Adalimumab was administered via the Pen or a prefilled syringe in theabdomen or thigh to healthy adult volunteers in this Phase I,open-label, parallel group, multicenter study. Regimen A included a40-mg subcutaneous dose of adalimumab via autoinjector pen, whileRegimen B included a 40-mg subcutaneous dose of adalimumab via prefilledsyringe.

Blood samples were collected by venipuncture prior to dosing (Hour 0);at Hours 4, 12, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 168,192, 240, 288, 336, and 360; and at Weeks 3, 4, 5, 6, 7, and 8 afterdosing. Serum concentrations of adalimumab were determined using avalidated double antigen immunoassay. The assay had a lower limit ofquantification of 3.125 ng/mL in diluted serum.

Main Inclusion Criteria included 18-55 years of age and patients were ingeneral good health. Main Exclusion Criteria included pregnancy and ahistory of positive PPD skin test. Pharmacokinetic analysis includedanalyzing pharmacokinetic (PK) parameters that were estimated usingnon-compartmental methods. PK parameters included were: maximum observedserum concentration (Cmax); time to Cmax (Tmax); area under serumconcentration-time curve (AUC) from Hour 0-360 (AUC0-360); and AUC fromHour 0-1344 (AUC0-1344)

Statistical analysis was performed using the following considerations. Afour-way analysis of covariance (ANCOVA) was performed for Tmax and thelogarithms of AUC and Cmax with regimen, injection site, study center,and sex as the factors. Body weight was the covariate. To assessbioequivalence of the regimens, a two one-sided test procedure wascarried out for AUC and Cmax via 90% confidence intervals for the ratioof regimen central values. The ratio of regimen central valuescorresponds to the difference of the regimen main effects in the ANCOVAmodel.

Safety was evaluated based on assessments of adverse events (AEs),physical examinations, vital signs, and laboratory tests

A total of 295 male and female healthy volunteers enrolled in the study.Of these, 146 volunteers received a 40-mg dose of adalimumab via anautoinjector pen and 149 subjects received a 40-mg dose of adalimumabvia a prefilled syringe. Table 7 contains the summary statistics fordemographic parameters

TABLE 7 Baseline Demographic Variables All Randomized CharacteristicsVolunteers (N = 295) Age (years) 37.5 ± 10.6 Weight (kg) 72.4 ± 10.9Height (cm) 168.9 ± 9.8  BMI 25.3 ± 2.7  % Male 49 % Caucasian 81 Allvalues are Mean ± SD, except percentages.

Mean serum adalimumab concentration-time profiles were similar in thetwo regimens. The pharmacokinetic profiles of the pen and prefilledsyringe were also comparable between the two injections sites, thigh andabdomen.

Pharmacokinetic parameters of adalimumab after administration of each ofthe two regimens were similar (Table 8). The Tmax, log-transformed Cmax,AUC0-360, and AUC0-1344 central values for the Pen were notstatistically significantly different from those for the prefilledsyringe (Table 8).

TABLE 8 Adalimumab Pharmacokinetic parameters in the Autoinjector Penand the Prefilled Syringe Regimens Adalimumab via Adalimumab viaPharmacokinetic Autoinjector Pen prefilled syringe Parameters (N = 146)(N = 147)* Tmax (hours) 142.3 ± 76.2 151.4 ± 88.5 Cmax (μg/mL)  4.8 ±1.5  4.8 ± 1.5 AUC0-360 (μg · hr/mL) 1260 ± 352 1276 ± 373 AUC0-1344 (μg· hr/mL) 2454 ± 815 2544 ± 952 *N = 146 for AUC0-360 and AUC0-1344. Inboth regimens a single 40-mg dose of adalimumab is administeredsubcutaneously. All values are Mean ± SD.

The 90% confidence intervals for log-transformed AUC0-360, AUC0-1344,and Cmax were contained within the 0.80 to 1.25 range indicating thatthe autoinjector test Regimen A was bioequivalent to the prefilledsyringe reference Regimen B at both subcutaneous locations, thigh andabdomen (Table 9)

TABLE 9 Relative Bioavailability and 90% Confidence Intervals for theBioequivalence Assessment by Injection Site Relative Central Value*Bioavailability Prefilled Point 90% Regimens PK Pen† Syringe† Esti-Confidence A vs. B Parameters (N = 146) (N = 149) mate‡ Interval AbdomenCmax 4.43 4.38 1.012 0.922-1.111 AUC0-360 1166 1138 1.025 0.931-1.129AUC0-1344 2169 2242 0.968 0.858-1.091 Thigh Cmax 4.62 4.89 0.9440.860-1.037 AUC0-360 1205 1319 0.914 0.829-1.007 AUC0-1344 2332 25470.915 0.812-1.033 *Antilogarithm of the least squares means forlogarithms. †Regimen A: 40 mg adalimumab administered subcutaneously viaan autoinjector. Regimen B: 40 mg adalimumab administered subcutaneouslyvia a prefilled syringe. ‡Antilogarithm of the difference (Pen minusprefilled syringe) of the least squares means for logarithms.

The autoinjector was well-tolerated in this study, with a safety profilecomparable to that of the prefilled syringe (Table 10)

TABLE 10 Adverse Events ≧2% in the Population Autoinjector Pen PrefilledSyringe N = 146 N = 149 n (%) n (%) Any AE 70 (48) 60 (40) Headache 29(20) 28 (19) Upper Respiratory Tract Infection 9 (6) 13 (9)  NasalCongestion 9 (6) 7 (5) Pain (Limbs) 2 (1) 7 (5) Constipation 7 (5) 2 (1)

No deaths or discontinuations due to adverse events occurred during thestudy. One volunteer reported a serious adverse event of appendicitisrequiring surgery and hospitalization on Study Day 20. The subjectrequested to continue participation in the study following her releasefrom the hospital, and was allowed to continue following a completemedical evaluation. The majority of the treatment-emergent adverseevents were assessed by the investigators as not related or possiblyrelated to the study drug and mild in severity.

In conclusion, the autoinjector pen was bioequivalent to the prefilledsyringe. The two regimens were also bioequivalent at each injectionsite, abdomen and thigh. The safety profile of the pen was comparable tothe safety profile of the prefilled syringe

EXAMPLE 3 Introduction of a HUMIRA® Automatic Injection Device asCompared to a Pre-Filled Syringe for Delivery of HUMIRA®

A HUMIRA® representative visits a physician who has previouslyprescribed HUMIRA® PFS to patients. The representative delivers an oralpresentation to the physician in which the TOUCH study and the resultsthereof are described for the physician (for TOUCH study, see, forexample, Example 1 above). In particular, the representative conveys tothe physician that 90% of patients reported an overall preference forthe HUMIRA® Pen compared to the PFS, 8 out of 10 would recommend the Pento other HUMIRA® patients and 80% of patients rated the Pen as lesspainful than the PFS. Additionally, the representative provides to thephysician a flipchart and a DVD, each of which describe the TOUCH studyand convey that 90% of patients reported an overall preference for theHUMIRA® Pen compared to the PFS, 8 out of 10 would recommend the Pen toother HUMIRA® patients and 80% of patients rated the Pen as less painfulthan the PFS.

EXAMPLE 4 Methods of Training for Use of a HUMIRA® Automatic InjectionDevice

A HUMIRA® representative visits a physician who has previouslyprescribed HUMIRA® PFS to patients. The representative delivers an oralpresentation to the physician describing how the HUMIRA® Pen is used todeliver a dose of HUMIRA® to a patient. This presentation includesinstructions to carry out the following steps:

-   -   (i) remove the HUMIRA Pen from the refrigerator 15 to 20 minutes        before injection;    -   (ii) choose an injection site on thigh or stomach (wherein the        site should be at least one inch from a previous injection site        and at least two inches from the navel) and wipe the injection        site with an alcohol swab;    -   (iii) examine the HUMIRA® solution in the HUMIRA® Pen through a        window in the Pen to make sure that the liquid is clear and        colorless. Also, holding the Pen such that the needle end is        pointing downward, check to make sure that the level of the        liquid is the same as or close to a line visible through the        window (to ensure the proper dosage is present);    -   (iv) remove caps from the needle end and activator button end of        the Pen. Gently squeeze a sizeable area of cleaned skin and        place the Pen at a 90-degree angle flush against the skin. Press        the activator button, keeping the Pen firmly against the skin,        and listen for a “click”. Maintain pressure on the activator        button and count to 10 seconds. Ensure that the yellow indicator        in the display window appears in full view and stops; and    -   (v) dispose of the Pen in an appropriate container (e.g., a        Sharps container).

Additionally, the representative provides to the physician a flipchartand a DVD that convey the instructions to carry out steps (i) to (v) asset forth above. Additionally, the representative provides to thephysician a training kit, wherein the kit includes (1) a demonstrationautomatic injection device, which mimics the HUMIRA® Pen but lacks theneedle and the HUMIRA® dose, (2) a brochure that conveys instructions tocarry out steps (i) to (v) as set forth above and (3) an audiovisualdevice (VHS cassette or DVD) that conveys instructions to carry outsteps (i) to (v) as set forth above.

Equivalents

Those skilled in the art will recognize, or be able to ascertain usingno more than routine experimentation, many equivalents to the specificembodiments of the invention described herein. Such equivalents areencompassed by the following claims. The contents of all references,patents, patent applications, and published patent applications citedthroughout this application are incorporated herein by reference.

1. A training device for training a recipient on administration of asubstance, the system comprising: a circular outer housing; anactivation button operatively coupled to the housing; and an audiblemechanism to convey audible information to a user concerning operationof the training automatic injector. 2-33. (canceled)